- Email: [email protected]
A Just Culture for Nurses and Nursing Students
A J u s t C u l t u re f o r N u r s e s and Nursing Students Jane Barnsteiner,
PhD, RN
a,
*, Joanne Disch,
PhD, RN
b
KEYWORDS Just culture Just culture and patient safety Blame culture Patient safety KEY POINTS Evidence suggests that failure to trend and track errors and to learn from them actually increases the likelihood of other errors and near misses. A culture has to be created in both clinical settings and schools of nursing in which confidential reporting as well as trending of errors and near misses helps identify problems and directs action to improve system issues.
Historically, a culture of blame has been the norm in health care in which individual practitioners were held accountable for any error or near miss. This culture often has led to secrecy and failure to report for fear of repercussions. At present, evidence suggests that failure to trend and track errors and learn from them actually increases the likelihood of other errors and near misses.1 Health care workers report only 2% to 3% of major errors that cannot be concealed.2 Thus, the focus has been shifting in practice settings toward efforts to create fair, just, and transparent cultures in which health care providers are encouraged to share information on situations that resulted in an error or a near miss so that the underlying issues in the system can be identified and corrected. A recent development is in creating fair and just cultures as well as systems for tracking errors and near misses in schools of nursing. This article provides an overview of current safety science related to just cultures, the tracking of errors and near misses, and individual and system responsibilities for promoting safe practice; and applies these principles to schools of nursing. BACKGROUND A Just Culture
A just culture is “one in which the reporting of errors and near misses is supported without fear of retribution.”3,4 This culture creates an atmosphere of trust, encouraging The authors have nothing to disclose. a University of Pennsylvania School of Nursing, Philadelphia, PA, USA; b University of Minnesota School of Nursing, Minneapolis, MN, USA * Corresponding author. 3131 East Calhoun Parkway, Minneapolis, MN 55408. E-mail address: [email protected] Nurs Clin N Am 47 (2012) 407–416 http://dx.doi.org/10.1016/j.cnur.2012.05.005 nursing.theclinics.com 0029-6465/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.
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and rewarding people for providing essential safety-related information so that learning can arise from mistakes and efforts can be directed toward fixing system issues, rather than blaming the individuals who make mistakes.5 This culture is essential for achieving safe and quality care. Over the past 10 years, much attention has been paid toward creating just and fair cultures in health care facilities. Safe culture focuses on effective teamwork to accomplish safe high-quality health care. During an adverse event, the focus is on what went wrong and not who the problem is. This culture requires a climate that fosters trust, where frontline providers are encouraged and willing to report errors, incidents, and near misses, including their own and those of others, yielding key information about safety problems and potential solutions. This attitude promotes self-reflection and adherence to safe practice through evaluation of one’s own practice. A just culture is not a culture of no-blame, in which individuals can make mistakes with impunity or through reckless behavior. Marx4 acknowledges that there is acceptable and unacceptable behavior, some of which is inherently culpable and must be treated as such. Just culture is the balance between the need to learn from our mistakes and the need to take disciplinary action, which must be addressed. A safety culture is just, promotes learning, informative, and flexible.6 A fair and just culture
The notion of fairness is a critical component of a just culture.7 People care about not only the fairness of the outcomes that they receive but also the fairness of the procedures used to decide the outcomes. In a fair and just culture, clinicians know they may speak safely on issues regarding their own actions or those in the environment around them. They feel physically and emotionally safe while working; are able to perform at peak capacity; admit weakness, concern, or inability, at any time; and seek assistance when concerned that the quality and safety of the care being delivered is threatened. Each person believes he/she is equally accountable for maintaining the environment and for delivering outstanding care. Individuals are comfortable monitoring others working with them and detecting the needs for assistance. They know that they are accountable for their actions, but will not be blamed for faults in the system beyond their control. This state is achievable when outstanding leadership, from the chair of the board down to the chief executive officer, ensures that every employee clearly understands her/his individual accountability and that executive leaders model this behavior. A Culture of Blame
The alternative to a just culture, a culture of blame, has been pervasive in health care, focusing primarily on who has been at fault and, all too often, what should be the punishment. This approach takes a backward-looking, retributive approach rather than a forward-looking, change-oriented approach. The retributive approach acted as a deterrent, that is, punishment for making an error would deter individuals from making them. In actuality, research indicates that rather than deterring individuals from making mistakes, a culture of blame results in hiding rather than reporting errors.1 This approach has become a major issue in generating accurate reports on errors and near misses in hospitals, to use that information to identify their causes, so as to put changes in place to prevent or minimize complications and mitigate harm. Anxiety related to committing errors and having to hide them leads to defensive medicine, not high-quality care with continuous improvement. Cohen and Shastay8 surveyed nurses on their errors in medication and approximately, 37% of nurses reported that they had not reported an error that might be personally or professionally damaging. The reasons for not reporting included fear of reprisal, not understanding the value of reporting, and believing that reports automatically go into the human resources file. This issue is not limited to health
A Just Culture for Nurses and Nursing Students
care alone. Ruitenberg9 reported a 50% drop in incident reports after the prosecution of air traffic controllers who had been involved in near miss situations. Definitions of an Error or Near Miss
James Reason,6 an eminent researcher in the area of human error, defines error as “circumstances in which planned actions fail to achieve the desired outcome.”10 He used Rasmussen’s 3 levels of performance to further differentiate errors Skill-based errors, slips and lapses, when the action is not what was intended Rule-based mistakes, actions that match intentions but do not achieve their intended outcome because of incorrect application of a rule or inadequacy of the plan. Knowledge-based mistakes, actions which are intended but do not achieve the intended outcome because of knowledge deficits. A subset of errors is medication errors, or errors occurring in some part of the ordering, dispensing, administering, and recording of medications. The National Coordinating Council for Medication Error and Prevention11 uses the following working definition for medication error: “. any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems including: prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.” Another form of error is the adverse event, or “an injury caused by medical management rather than the underlying condition of the patient.” An adverse event attributable to error is a “preventable adverse event.”12 The definition of a near miss is even more ambiguous. The Institute for Safe Medication Practices (ISMP)13 defines it as “an event, situation, or error that took place but was captured before reaching the patient.” This definition varies somewhat from the definition by the Agency for Healthcare Research and Quality, which defines a near miss as “event or situation that did not produce patient injury, but only because of chance.” The latter definition is not clear as to whether the event reached the patient and fails to provoke system assessment because chance, not preventable action, was operating. ISMP actually recommends that the term ‘close call’ be used although they acknowledge the prevailing usage of the term near miss.13 The extent of errors in health care is enormous, and likely understated. An estimated 20% of all medications administered have some component of error (wrong person, site, route, etc), and the Institute of Medicine (IOM) report To Err is Human14 projected that up to 98,000 die each year from medical error. Pfeiffer and colleagues15 identified several barriers to the reporting of errors or near misses. First were attitudes, such as concern about being blamed, judged incompetent, and making colleagues look bad. Second was related to concerns about the reporting system, such as not knowing how or where to report, or being too timeconsuming or not receiving any feedback to know what happened as a result of the report. Finally, there were other influences in the decision to file a report, such as the perception that there was no point if there was no harm to the patient. ACCOUNTABILITY Organization and System Accountability
Increasingly, patient safety experts seek the right balance between identifying the contribution to the error of the individual practitioner and the system. Where previously
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individuals were largely held responsible for errors, safety science suggests that system complexity plays a larger role in errors than the individual practitioner. Patient safety in the current health care environment relies on the coordination, input, and vigilance of many moving parts. Multiple providers, frequent handoffs, and complex interactions make it virtually impossible for a single clinician to own all the events involved in an individual patient’s care. Delivering a single medication may involve as many as 6 steps or handoffs.16 For the Boston Globe reporter who died after receiving 4 times the intended dose of chemotherapy, the erroneous medication order passed through the hands of nearly 25 health care providers.17 A just culture is founded on accountability. The most visible manifestation of institutional accountability is the public reporting of health care outcomes. But collective accountability requires an organization to answer to several other factors: outdated work systems that can’t support contemporary hospitals’ complex environments, limited or absence of information technology and poorly designed health records, nonstandardized handoffs, faulty discharge processes, and unreasonable expectations that highly trained, dedicated, and capable caregivers will perform flawlessly 24 h/d, 7 d/wk.18 Other institutional responsibilities in a collective accountability framework include developing robust nonpunitive reporting systems, supporting clinicians after adverse events and medical error, and developing ways to inform and compensate patients who are harmed by system errors. Organizations also need to enforce achievement and maintenance of competency to ensure adherence to quality benchmarks and evidence-based care, and to develop mechanisms to identify and rehabilitate impaired clinicians.1,19 Collective accountability engages all involved providers to think carefully about system solutions.20 The Joint Commission published a Sentinel Event Alert21 on Leadership Committed to Safety emphasizing the responsibility of leaders to institute organization-wide policies, such as those listed above, and a mandate for transparency that sheds light on all adverse events and patient safety issues within an organization, thereby creating an environment where it is safe for everyone to talk about real and potential organizational vulnerabilities and to support each other in an effort to report vulnerabilities and failures without fear of reprisal. Leaders are increasingly being held accountable for implementing the necessary policies, systems, and practices for creating safe environments, blame-free error reporting, and directing sufficient resources to the achievement of safe quality care. Individual Accountability
The concept of accountability also includes the responsibilities of the individual toward his/her understanding of the actions to be performed, a clear expectation of what those actions are, and the means by which performance will be evaluated. An environment of just culture changes the response to the error, but maintains the accountability for the error.22 Behavioral choice, intention, and response matter in individual accountability. Behaviors are frequently categorized into 3 types: Human error is defined by the ISMP as involving unintentional and unpredictable behaviors that result in or may cause an undesirable outcome.13 At-risk behavior is defined as drifting into unsafe habits, possibly negligence, and carelessness. Reckless behavior is described as conscious disregard, and the person committing the error understands and knows the risk he or she is taking and makes a conscious choice to do it anyway.
A Just Culture for Nurses and Nursing Students
In a fair and just culture, the clinician is accountable for knowingly and unnecessarily increasing risk. Reason3,6 and Marx4 have emphasized the importance of establishing general agreement on demarcating culpable and nonculpable unsafe acts. Accountability for an error or near miss is often determined by the outcome of the adverse event. The worse the outcome, severe disability or death, the more egregious the incident is considered and the more severe the punishment of the individual. From the perspective of systems improvement, however, learning and positive change are more likely to occur, when the outcome is independent from the evaluation of an adverse event. Targeting only situations in which there is significant disability overlooks the impact of a consistently careless practitioner who commits frequent errors but none resulting in disability or death. If there is negligence, recklessness, or willful violation of policies, corrective action would be indicated, including remedial help, repeating of a course, or dismissal if warranted. Industries Outside Health Care
Although incorporation of a fair and just culture is fairly recent in health care, the concepts are embedded in other industries perceived as reliable and safe. Knowledge about human behavior led to the science of human factors in aviation, which helped shape the industry through the adoption of standardization and simplification rules to produce greater reliability and safety. For over a quarter century, an errorreporting system paid for by the federal government through the Federal Aviation Administration and managed by National Aeronautics and Space Administration has been extensively used.23 This system has evolved to open-reporting systems administered within specific airlines. Pilots have been trained for the past 30 years to understand and admit their fallibility, and their industry promotes a discussion, on a regular basis, on individual failing. Pilots are regularly evaluated for both their technical skill and their ability to promote effective teamwork. Furthermore, they practice recovery for situations deliberately set up to fail. The application of human factors is uniformly manifest, and the result is an extraordinary safety record. Moving to a Fair and Just Culture
There has been a dearth of research on effective interventions to move from a blame culture to a just culture. Recent reports indicate that a blame culture is the norm in the majority of hospitals. Farley and colleagues24 studied the adverse event reporting practices of hospitals in the United States and found that only 32% of hospitals have environments that support reporting, 13% have broad staff involvement in reporting adverse events, and 21% have transparent processes in which the reports are distributed and discussed. Organizations that implement just culture recognize the barriers and challenges in transparency and any fear that the staff may have and consider them when moving to a just culture. Organizations that have not implemented just culture paradoxically report a higher perception of staff not being afraid to report, and having a misguided belief about the actual rate of errors and near misses, indicating that they may not be in touch with how staff really fear punitive actions.25 Moving to a fair and just culture is not easy. Just culture is not merely a matter of implementing good reporting systems and encouraging people to use them but a huge cultural shift from a bureaucratic to a shared decision management style. Just culture requires quality to be part of everyone’s role, shared discussion and decision making, uninhibited reporting, strong feedback systems, as well as rapid analysis and follow-up of errors and near misses. Box 1 notes the questions to be answered when moving to a fair and just culture.26
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Box 1 Questions to be addressed when moving to a just culture Why is a change to a Just Culture important? How is everyone in the organization a stakeholder in the change? What impact will the change have on quality of patient care? How will the information be communicated throughout the organization? How will the reporting system change? How will patient confidentiality be maintained? What will it look like in our work area? Are there any work area specific practices that should be addressed? What are the potential barriers to success? How will ongoing evaluation occur? Adapted from Shepard LH. Creating a foundation for a just culture workplace. Nursing 2011;41:46–8.
Just Culture in Schools of Nursing
To prepare students to practice effectively in this environment, faculty members must help them develop the appropriate values and competencies while in school, even when making mistakes. However, most schools do not have formal reporting mechanisms and processes to analyze, trend, and correct problems related to errors and near misses. A culture has to be created in schools of nursing in which confidential reporting as well as trending of errors and near misses to help identify problems and direct actions to improve system issues. To help student nurses become competent novice nurses, systems and structures that allow for reporting, trending and analysis of errors and near misses must be implemented. Key first steps include establishing reporting and trending mechanisms so that appropriate interventions can be implemented to reduce errors and near misses. These steps allow the creation of a baseline, and with the information generated from it, appropriate interventions can be designed to reduce errors and near misses. Schools of nursing have not kept pace with this philosophic change. Too often, schools continue to operate in an environment of secrecy, shame, and blame. Rather than learning from student errors or near misses, students may be counseled, reprimanded, or dismissed. Few schools have policies in place on how to address these errors and near misses, reflecting a belief that “students shouldn’t make mistakes” and “if you’re a good faculty member, your students don’t make mistakes.” Faculty members are often reluctant to share information on student performance among each other, believing that such information will influence a colleague’s view of a student. Thus, students can reach their final semester not having received the coaching needed. In some settings, faculty members are reprimanded (or terminated) if their students make mistakes. There can be concerns, valid or not, that clinical agencies will not allow schools to have clinical slots if their students have made mistakes. These are characteristics of a culture of shame and blame: where mistakes are always viewed as preventable through individual vigilance, where acknowledging that there are gradations among them, and where there is a need to capture their existence, somehow condones them. Because of such beliefs, very few schools of nursing have instituted formal error and near miss reporting systems, data bases on the
A Just Culture for Nurses and Nursing Students
number and kind of errors, or trending reports that would enable examination of precipitating factors and vulnerabilities in their educational programs. Hence graduates enter the practice world not having been socialized to a culture that promotes self-reflection, transparency, and system safety. The Extent of Errors and Near Misses by Students
Knowledge on the extent and type of errors and near misses among nursing students is limited. Wolf and colleagues,27 using the online database, MEDMARX, analyzed the reports of medication errors involving nursing students. This national database has a checkoff for those involved in the error and includes student nurse on the list and, hence, enables tracking of errors by students, but it is limited to medication errors. There were 1300 errors reported as involving student nurses over a 5-year period, associated with giving medications to the wrong patient, at the wrong time, or by the wrong route. In 2008, Harding and Petrick28 performed a 3-year retrospective analysis of 77 medication errors by students in 1 baccalaureate program. Through examining student incident reports, they found that 43% of errors were related to inexperience in reading the clinical agency’s Medication Administration Record. Because of this work, the school changed its policy so that, rather than the form being put in the student’s file, it was kept in a general incident file and reviewed for trend identification. This school of nursing, in turn, shared this information with the clinical agency so that practices could be modified to improve safety. Reid-Searl and colleagues29 interviewed 28 students, with 9 reporting making errors or near misses. Reasons for the errors included not being supervised by the nurse when this occurred as well as distractions and interruptions while engaged in the medication administration process. Most of the students were told that reporting the errors was not necessary because it was time consuming. In 2009, Currie and colleagues30 reported results from a web-based hazard and near miss reporting system they had developed for use by students. Over a 3-year period, 453 students reported 10,206 yes responses to whether they had ever been in a situation involving a hazard or near miss, 59% of which were hazards and 42% near misses. Hazards included items such as infection, equipment and device failures, medication-related situations, and environmental hazards. Students identified several additional hazards, such as the disclosure of patient information in public places and absence of identification bands on patients’ wrists, among others. These distinctions in the terms and definition are critically important to develop an accurate and actionable database. Depending on the organization or the faculty member’s personal philosophy, a near miss may be equivalent to an error. For example, faculty members have commented that if a student incorrectly draws up a medication and it is caught by the faculty member, it is an error, whereas others would see it as a near miss. And if the school’s policy, explicit or not, is that 2 errors of any sort are grounds for dismissal, it is clear that there are significant implications in naming and handling errors and near misses. There has been very little published on just cultures in schools of nursing, although this trend is slowly changing. One very relevant report on the Internet describes work that has been done by the North Carolina State Board of Nursing.31 In Pilot Project, they developed a framework for reviewing practice issues, developed and offered education programs on just culture to hospitals and nursing homes, and created a Complaint Evaluation Tool to assess deviations in nursing practice and to determine what is reportable. In one very innovative approach, the University of San Francisco has created the position of Director of Quality and Safety. There is a need to prepare students for contemporary nursing practice in all of its dimensions. In addition to teaching students to be competent novice nurses, this means
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putting in place systems and structures that allow for trending and analysis of errors and near misses, and creating transparent and just cultures in which both nursing faculty and students can learn from mistakes and identify system issues that can be corrected to prevent them in the future. A key first step in transforming nursing education is creating that awareness and commitment to just culture in schools of nursing, establishing a national data repository so that a baseline can be created, and with the information generated from it, designing appropriate interventions to reduce errors and near misses. There is no universal understanding, agreement, or comfort in tracking student errors and changing the culture to become one of learning from them. Among some faculty members, there continues to be a strong belief that individual vigilance is what is required and that if an error or near miss occurs, the student is at fault. Other faculty members suggest that creating a database of errors and sharing information on their occurrence could somehow condone the commitment of errors and near misses. There is concern that if it becomes public knowledge that students are making errors, clinical facilities may be reluctant to have students from that school in their facilities. These responses are predictable and, actually, parallel the experiences of hospitals working to create systems to openly report adverse events. The IOM14 identified that to affect patient safety and error prevention, sufficient attention must be devoted to analyzing and understanding the causes of errors. Within the 6 competencies developed through the Quality and Safety Education for Nurses project to improve the quality and safety of nursing care,32 the Safety competency includes 2 skills directly related to a fair and just culture: (1) communicate observations or concerns related to hazards and errors to patients, families, and the health care team and (2) use organizational error reporting systems for near miss and error reporting. Implications for Nursing Education
There are numerous activities the schools of nursing may undertake to move to a fair and just safety culture. Engage faculty members in conversations about their views on errors and near misses Examine school policies related to student errors and analyze how they do or do not reflect the characteristics of a fair and just culture of safety Dialog with clinical partners to learn the state of their fair and just safety culture Discuss with clinical partners what they believe constitutes student errors and how they would like them to be reported and tracked Track and trend student errors and near misses to assess if there are organizational and individual considerations that may inform the curriculum
SUMMARY
At present, evidence suggests that failure to trend and track errors, and learning from them, actually increases the likelihood of other errors and near misses. A culture has to be created in both clinical settings and schools of nursing in which confidential reporting and trending of errors and near misses helps identify problems and directs action to improve system issues. This means implementing systems and structures that allow for trending and analysis of errors and near misses, and creating transparent and just cultures in which clinicians, nursing faculty and students can learn from mistakes and identify system issues that can be corrected to prevent them in the future because patients’ lives depend on it.
A Just Culture for Nurses and Nursing Students
REFERENCES
1. Henricksen K, Dayton E. Organizational silence and hidden threats to patient safety. Health Research and Eductional Trust 2006;41(4):1539–54. 2. Leape LL. When good doctors go bad: a systems problem. Ann Surg 2006; 244(5):649–52. 3. Reason J. Human error: models and management. BMJ 2000;320(7237):768–70. 4. Marx D. Patient safety and the ‘just culture:’ a primer for health care executives. New York: Columbia University; 2001. 5. vonThaden T, Hoppes M. Measuring a just culture in healthcare professionals: initial survey results. Proceedings from safety across high-consequence industries conference. St Louis (MO); 2005. p. 20–2. 6. Reason J. Human error. Cambridge (United Kingdom): Cambridge University Press; 1990. Available at: http://patientsafetyed.duhs.duke.edu/module_e/definitions.html. Accessed July 5, 2012. 7. Frankel AS, Leonard M, Denham C. Fair and just culture, team behavior, and leadership engagement: the tools to achieve high reliability HSR. Health Serv Res 2006;41(4 Pt 2):1690–709. 8. Cohen H, Shastay AD. Getting to the root of medication errors. Nursing 2008; 38(12):39–47. 9. Ruitenberg B. Court case against Dutch controllers. Controller 2002;41:22–5. 10. Department of Community and Family Medicine. Anatomy of an error. 2005. Available at: http://patientsafetyed.duhs.duke.edu/module_e/types_errors.html. Accessed July 5, 2012. 11. National Coordinating Council for Medication Error and Prevention. What is a medication error? 2011. Available at: http://www.nccmerp.org/aboutMedErrors.html. Accessed July 5, 2012. 12. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991;324(6):370–6. 13. Institute for Safe Medication Practices (ISMP). ISMP survey helps define nearmisses and close calls. 2005. Available at: http://www.ismp.org/Newsletters/ acutecare/articles/20090924.asp. Accessed July 5, 2012. 14. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academy Press; 2001. 15. Pfeiffer Y, Manser T, Wehner T. Conceptualising barriers to incident reporting: a psychological framework. Qual Saf Health Care 2010. http://dx.doi.org/ 10.1136/qshc.2008.030445. 16. Walsh KE, Kaushal R, Chessare JB. How to avoid paediatric medication errors: a user’s guide to the literature. Arch Dis Child 2005;90(7):698–702. 17. Allen S. With work, Dana Farber learns from 94 mistakes. Boston Globe 2004. 18. Casalino LP, Dunham D, Chin MH, et al. Frequency of failure to inform patients of clinically significant outpatient test results. Arch Intern Med 2009;169(12):1123–9. 19. Joint Commission. Behaviors that undermine a culture of safety. Joint Commission Web Site. 2008. Available at: http://www.jointcommission.org/sentinel_event_alert_issue_40_ behaviors_that_undermine_a_culture_of_safety/. Accessed January 29, 2012. 20. Bell S, Delbanco T, Anderson-Shaw L, et al. Accountability for medical error moving beyond blame to advocacy. Chest 2011;140(2):519–26. 21. Joint Commission. Sentinel Event Alert #43. Leadership committed to safety. 2009. Available at: http://www.jointcommission.org/sentinel_event_alert_issue_ 43_leadership_committed_to_safety. Accessed July 5, 2012.
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22. Gorzeman J. Balancing just culture with regulatory standards. Nurs Adm Q 2006; 32(4):308–11. 23. McGreevy MW, Ames Research Center. Searching the ASRS database using QUORUM keyword search, phrase search, phrase generation, and phrase discovery. Moffett Field (CA): National Aeronautics and Space Administration, Ames Research Center; 2001. Available from NASA Center for AeroSpace Information. 24. Farley DO, Haviland A, Champagne S, et al. Adverse-event reporting practices by US hospitals: Results of a national survey. Qual Health Care 2009;17:416–23. 25. Vogelsmeier J, Scott-Cawiezell L, Miller B, et al. Influencing leadership perceptions of patient safety through just culture training. J Nurs Care Qual 2010; 25(4):288–94. 26. Shepard LH. Creating a foundation for a just culture workplace. Nursing 2011; 41:46–8. 27. Wolf ZR, Hicks R, Serembus JF. Characteristics of medication errors made by students during the administration phase: a descriptive study. J Prof Nurs 2006;22(1):39–51. 28. Harding L, Petrick T. Nursing student medication errors: a retrospective review. J Nurs Educ 2008;47(1):43–7. 29. Reid-Searl K, Moxham L, Happell B. Enhancing patient safety: the importance of direct supervision for avoiding medication errors and near misses by undergraduate nursing students. Int J Nurs Pract 2010;16:225–32. 30. Currie LM, Desjardins KS, Levine E, et al. Web-based hazard and near-miss reporting as part of a patient safety curriculum. J Nurs Educ 2009;48(12):669–77. 31. North Carolina Board of Nursing. Improving nursing regulation: the just culture approach. 2010. Available at: http://www.nabp.net/query/q5improving1 nursing1regulation%3A1the1just1culture. Accessed July 5, 2012. 32. Cronenwett L, Sherwood G, Barnsteiner J, et al. Quality and safety education for nurses. Nurs Outlook 2007;55:122–31.
PhD, RN
a,
*, Joanne Disch,
PhD, RN
b
KEYWORDS Just culture Just culture and patient safety Blame culture Patient safety KEY POINTS Evidence suggests that failure to trend and track errors and to learn from them actually increases the likelihood of other errors and near misses. A culture has to be created in both clinical settings and schools of nursing in which confidential reporting as well as trending of errors and near misses helps identify problems and directs action to improve system issues.
Historically, a culture of blame has been the norm in health care in which individual practitioners were held accountable for any error or near miss. This culture often has led to secrecy and failure to report for fear of repercussions. At present, evidence suggests that failure to trend and track errors and learn from them actually increases the likelihood of other errors and near misses.1 Health care workers report only 2% to 3% of major errors that cannot be concealed.2 Thus, the focus has been shifting in practice settings toward efforts to create fair, just, and transparent cultures in which health care providers are encouraged to share information on situations that resulted in an error or a near miss so that the underlying issues in the system can be identified and corrected. A recent development is in creating fair and just cultures as well as systems for tracking errors and near misses in schools of nursing. This article provides an overview of current safety science related to just cultures, the tracking of errors and near misses, and individual and system responsibilities for promoting safe practice; and applies these principles to schools of nursing. BACKGROUND A Just Culture
A just culture is “one in which the reporting of errors and near misses is supported without fear of retribution.”3,4 This culture creates an atmosphere of trust, encouraging The authors have nothing to disclose. a University of Pennsylvania School of Nursing, Philadelphia, PA, USA; b University of Minnesota School of Nursing, Minneapolis, MN, USA * Corresponding author. 3131 East Calhoun Parkway, Minneapolis, MN 55408. E-mail address: [email protected] Nurs Clin N Am 47 (2012) 407–416 http://dx.doi.org/10.1016/j.cnur.2012.05.005 nursing.theclinics.com 0029-6465/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.
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and rewarding people for providing essential safety-related information so that learning can arise from mistakes and efforts can be directed toward fixing system issues, rather than blaming the individuals who make mistakes.5 This culture is essential for achieving safe and quality care. Over the past 10 years, much attention has been paid toward creating just and fair cultures in health care facilities. Safe culture focuses on effective teamwork to accomplish safe high-quality health care. During an adverse event, the focus is on what went wrong and not who the problem is. This culture requires a climate that fosters trust, where frontline providers are encouraged and willing to report errors, incidents, and near misses, including their own and those of others, yielding key information about safety problems and potential solutions. This attitude promotes self-reflection and adherence to safe practice through evaluation of one’s own practice. A just culture is not a culture of no-blame, in which individuals can make mistakes with impunity or through reckless behavior. Marx4 acknowledges that there is acceptable and unacceptable behavior, some of which is inherently culpable and must be treated as such. Just culture is the balance between the need to learn from our mistakes and the need to take disciplinary action, which must be addressed. A safety culture is just, promotes learning, informative, and flexible.6 A fair and just culture
The notion of fairness is a critical component of a just culture.7 People care about not only the fairness of the outcomes that they receive but also the fairness of the procedures used to decide the outcomes. In a fair and just culture, clinicians know they may speak safely on issues regarding their own actions or those in the environment around them. They feel physically and emotionally safe while working; are able to perform at peak capacity; admit weakness, concern, or inability, at any time; and seek assistance when concerned that the quality and safety of the care being delivered is threatened. Each person believes he/she is equally accountable for maintaining the environment and for delivering outstanding care. Individuals are comfortable monitoring others working with them and detecting the needs for assistance. They know that they are accountable for their actions, but will not be blamed for faults in the system beyond their control. This state is achievable when outstanding leadership, from the chair of the board down to the chief executive officer, ensures that every employee clearly understands her/his individual accountability and that executive leaders model this behavior. A Culture of Blame
The alternative to a just culture, a culture of blame, has been pervasive in health care, focusing primarily on who has been at fault and, all too often, what should be the punishment. This approach takes a backward-looking, retributive approach rather than a forward-looking, change-oriented approach. The retributive approach acted as a deterrent, that is, punishment for making an error would deter individuals from making them. In actuality, research indicates that rather than deterring individuals from making mistakes, a culture of blame results in hiding rather than reporting errors.1 This approach has become a major issue in generating accurate reports on errors and near misses in hospitals, to use that information to identify their causes, so as to put changes in place to prevent or minimize complications and mitigate harm. Anxiety related to committing errors and having to hide them leads to defensive medicine, not high-quality care with continuous improvement. Cohen and Shastay8 surveyed nurses on their errors in medication and approximately, 37% of nurses reported that they had not reported an error that might be personally or professionally damaging. The reasons for not reporting included fear of reprisal, not understanding the value of reporting, and believing that reports automatically go into the human resources file. This issue is not limited to health
A Just Culture for Nurses and Nursing Students
care alone. Ruitenberg9 reported a 50% drop in incident reports after the prosecution of air traffic controllers who had been involved in near miss situations. Definitions of an Error or Near Miss
James Reason,6 an eminent researcher in the area of human error, defines error as “circumstances in which planned actions fail to achieve the desired outcome.”10 He used Rasmussen’s 3 levels of performance to further differentiate errors Skill-based errors, slips and lapses, when the action is not what was intended Rule-based mistakes, actions that match intentions but do not achieve their intended outcome because of incorrect application of a rule or inadequacy of the plan. Knowledge-based mistakes, actions which are intended but do not achieve the intended outcome because of knowledge deficits. A subset of errors is medication errors, or errors occurring in some part of the ordering, dispensing, administering, and recording of medications. The National Coordinating Council for Medication Error and Prevention11 uses the following working definition for medication error: “. any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems including: prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.” Another form of error is the adverse event, or “an injury caused by medical management rather than the underlying condition of the patient.” An adverse event attributable to error is a “preventable adverse event.”12 The definition of a near miss is even more ambiguous. The Institute for Safe Medication Practices (ISMP)13 defines it as “an event, situation, or error that took place but was captured before reaching the patient.” This definition varies somewhat from the definition by the Agency for Healthcare Research and Quality, which defines a near miss as “event or situation that did not produce patient injury, but only because of chance.” The latter definition is not clear as to whether the event reached the patient and fails to provoke system assessment because chance, not preventable action, was operating. ISMP actually recommends that the term ‘close call’ be used although they acknowledge the prevailing usage of the term near miss.13 The extent of errors in health care is enormous, and likely understated. An estimated 20% of all medications administered have some component of error (wrong person, site, route, etc), and the Institute of Medicine (IOM) report To Err is Human14 projected that up to 98,000 die each year from medical error. Pfeiffer and colleagues15 identified several barriers to the reporting of errors or near misses. First were attitudes, such as concern about being blamed, judged incompetent, and making colleagues look bad. Second was related to concerns about the reporting system, such as not knowing how or where to report, or being too timeconsuming or not receiving any feedback to know what happened as a result of the report. Finally, there were other influences in the decision to file a report, such as the perception that there was no point if there was no harm to the patient. ACCOUNTABILITY Organization and System Accountability
Increasingly, patient safety experts seek the right balance between identifying the contribution to the error of the individual practitioner and the system. Where previously
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individuals were largely held responsible for errors, safety science suggests that system complexity plays a larger role in errors than the individual practitioner. Patient safety in the current health care environment relies on the coordination, input, and vigilance of many moving parts. Multiple providers, frequent handoffs, and complex interactions make it virtually impossible for a single clinician to own all the events involved in an individual patient’s care. Delivering a single medication may involve as many as 6 steps or handoffs.16 For the Boston Globe reporter who died after receiving 4 times the intended dose of chemotherapy, the erroneous medication order passed through the hands of nearly 25 health care providers.17 A just culture is founded on accountability. The most visible manifestation of institutional accountability is the public reporting of health care outcomes. But collective accountability requires an organization to answer to several other factors: outdated work systems that can’t support contemporary hospitals’ complex environments, limited or absence of information technology and poorly designed health records, nonstandardized handoffs, faulty discharge processes, and unreasonable expectations that highly trained, dedicated, and capable caregivers will perform flawlessly 24 h/d, 7 d/wk.18 Other institutional responsibilities in a collective accountability framework include developing robust nonpunitive reporting systems, supporting clinicians after adverse events and medical error, and developing ways to inform and compensate patients who are harmed by system errors. Organizations also need to enforce achievement and maintenance of competency to ensure adherence to quality benchmarks and evidence-based care, and to develop mechanisms to identify and rehabilitate impaired clinicians.1,19 Collective accountability engages all involved providers to think carefully about system solutions.20 The Joint Commission published a Sentinel Event Alert21 on Leadership Committed to Safety emphasizing the responsibility of leaders to institute organization-wide policies, such as those listed above, and a mandate for transparency that sheds light on all adverse events and patient safety issues within an organization, thereby creating an environment where it is safe for everyone to talk about real and potential organizational vulnerabilities and to support each other in an effort to report vulnerabilities and failures without fear of reprisal. Leaders are increasingly being held accountable for implementing the necessary policies, systems, and practices for creating safe environments, blame-free error reporting, and directing sufficient resources to the achievement of safe quality care. Individual Accountability
The concept of accountability also includes the responsibilities of the individual toward his/her understanding of the actions to be performed, a clear expectation of what those actions are, and the means by which performance will be evaluated. An environment of just culture changes the response to the error, but maintains the accountability for the error.22 Behavioral choice, intention, and response matter in individual accountability. Behaviors are frequently categorized into 3 types: Human error is defined by the ISMP as involving unintentional and unpredictable behaviors that result in or may cause an undesirable outcome.13 At-risk behavior is defined as drifting into unsafe habits, possibly negligence, and carelessness. Reckless behavior is described as conscious disregard, and the person committing the error understands and knows the risk he or she is taking and makes a conscious choice to do it anyway.
A Just Culture for Nurses and Nursing Students
In a fair and just culture, the clinician is accountable for knowingly and unnecessarily increasing risk. Reason3,6 and Marx4 have emphasized the importance of establishing general agreement on demarcating culpable and nonculpable unsafe acts. Accountability for an error or near miss is often determined by the outcome of the adverse event. The worse the outcome, severe disability or death, the more egregious the incident is considered and the more severe the punishment of the individual. From the perspective of systems improvement, however, learning and positive change are more likely to occur, when the outcome is independent from the evaluation of an adverse event. Targeting only situations in which there is significant disability overlooks the impact of a consistently careless practitioner who commits frequent errors but none resulting in disability or death. If there is negligence, recklessness, or willful violation of policies, corrective action would be indicated, including remedial help, repeating of a course, or dismissal if warranted. Industries Outside Health Care
Although incorporation of a fair and just culture is fairly recent in health care, the concepts are embedded in other industries perceived as reliable and safe. Knowledge about human behavior led to the science of human factors in aviation, which helped shape the industry through the adoption of standardization and simplification rules to produce greater reliability and safety. For over a quarter century, an errorreporting system paid for by the federal government through the Federal Aviation Administration and managed by National Aeronautics and Space Administration has been extensively used.23 This system has evolved to open-reporting systems administered within specific airlines. Pilots have been trained for the past 30 years to understand and admit their fallibility, and their industry promotes a discussion, on a regular basis, on individual failing. Pilots are regularly evaluated for both their technical skill and their ability to promote effective teamwork. Furthermore, they practice recovery for situations deliberately set up to fail. The application of human factors is uniformly manifest, and the result is an extraordinary safety record. Moving to a Fair and Just Culture
There has been a dearth of research on effective interventions to move from a blame culture to a just culture. Recent reports indicate that a blame culture is the norm in the majority of hospitals. Farley and colleagues24 studied the adverse event reporting practices of hospitals in the United States and found that only 32% of hospitals have environments that support reporting, 13% have broad staff involvement in reporting adverse events, and 21% have transparent processes in which the reports are distributed and discussed. Organizations that implement just culture recognize the barriers and challenges in transparency and any fear that the staff may have and consider them when moving to a just culture. Organizations that have not implemented just culture paradoxically report a higher perception of staff not being afraid to report, and having a misguided belief about the actual rate of errors and near misses, indicating that they may not be in touch with how staff really fear punitive actions.25 Moving to a fair and just culture is not easy. Just culture is not merely a matter of implementing good reporting systems and encouraging people to use them but a huge cultural shift from a bureaucratic to a shared decision management style. Just culture requires quality to be part of everyone’s role, shared discussion and decision making, uninhibited reporting, strong feedback systems, as well as rapid analysis and follow-up of errors and near misses. Box 1 notes the questions to be answered when moving to a fair and just culture.26
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Box 1 Questions to be addressed when moving to a just culture Why is a change to a Just Culture important? How is everyone in the organization a stakeholder in the change? What impact will the change have on quality of patient care? How will the information be communicated throughout the organization? How will the reporting system change? How will patient confidentiality be maintained? What will it look like in our work area? Are there any work area specific practices that should be addressed? What are the potential barriers to success? How will ongoing evaluation occur? Adapted from Shepard LH. Creating a foundation for a just culture workplace. Nursing 2011;41:46–8.
Just Culture in Schools of Nursing
To prepare students to practice effectively in this environment, faculty members must help them develop the appropriate values and competencies while in school, even when making mistakes. However, most schools do not have formal reporting mechanisms and processes to analyze, trend, and correct problems related to errors and near misses. A culture has to be created in schools of nursing in which confidential reporting as well as trending of errors and near misses to help identify problems and direct actions to improve system issues. To help student nurses become competent novice nurses, systems and structures that allow for reporting, trending and analysis of errors and near misses must be implemented. Key first steps include establishing reporting and trending mechanisms so that appropriate interventions can be implemented to reduce errors and near misses. These steps allow the creation of a baseline, and with the information generated from it, appropriate interventions can be designed to reduce errors and near misses. Schools of nursing have not kept pace with this philosophic change. Too often, schools continue to operate in an environment of secrecy, shame, and blame. Rather than learning from student errors or near misses, students may be counseled, reprimanded, or dismissed. Few schools have policies in place on how to address these errors and near misses, reflecting a belief that “students shouldn’t make mistakes” and “if you’re a good faculty member, your students don’t make mistakes.” Faculty members are often reluctant to share information on student performance among each other, believing that such information will influence a colleague’s view of a student. Thus, students can reach their final semester not having received the coaching needed. In some settings, faculty members are reprimanded (or terminated) if their students make mistakes. There can be concerns, valid or not, that clinical agencies will not allow schools to have clinical slots if their students have made mistakes. These are characteristics of a culture of shame and blame: where mistakes are always viewed as preventable through individual vigilance, where acknowledging that there are gradations among them, and where there is a need to capture their existence, somehow condones them. Because of such beliefs, very few schools of nursing have instituted formal error and near miss reporting systems, data bases on the
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number and kind of errors, or trending reports that would enable examination of precipitating factors and vulnerabilities in their educational programs. Hence graduates enter the practice world not having been socialized to a culture that promotes self-reflection, transparency, and system safety. The Extent of Errors and Near Misses by Students
Knowledge on the extent and type of errors and near misses among nursing students is limited. Wolf and colleagues,27 using the online database, MEDMARX, analyzed the reports of medication errors involving nursing students. This national database has a checkoff for those involved in the error and includes student nurse on the list and, hence, enables tracking of errors by students, but it is limited to medication errors. There were 1300 errors reported as involving student nurses over a 5-year period, associated with giving medications to the wrong patient, at the wrong time, or by the wrong route. In 2008, Harding and Petrick28 performed a 3-year retrospective analysis of 77 medication errors by students in 1 baccalaureate program. Through examining student incident reports, they found that 43% of errors were related to inexperience in reading the clinical agency’s Medication Administration Record. Because of this work, the school changed its policy so that, rather than the form being put in the student’s file, it was kept in a general incident file and reviewed for trend identification. This school of nursing, in turn, shared this information with the clinical agency so that practices could be modified to improve safety. Reid-Searl and colleagues29 interviewed 28 students, with 9 reporting making errors or near misses. Reasons for the errors included not being supervised by the nurse when this occurred as well as distractions and interruptions while engaged in the medication administration process. Most of the students were told that reporting the errors was not necessary because it was time consuming. In 2009, Currie and colleagues30 reported results from a web-based hazard and near miss reporting system they had developed for use by students. Over a 3-year period, 453 students reported 10,206 yes responses to whether they had ever been in a situation involving a hazard or near miss, 59% of which were hazards and 42% near misses. Hazards included items such as infection, equipment and device failures, medication-related situations, and environmental hazards. Students identified several additional hazards, such as the disclosure of patient information in public places and absence of identification bands on patients’ wrists, among others. These distinctions in the terms and definition are critically important to develop an accurate and actionable database. Depending on the organization or the faculty member’s personal philosophy, a near miss may be equivalent to an error. For example, faculty members have commented that if a student incorrectly draws up a medication and it is caught by the faculty member, it is an error, whereas others would see it as a near miss. And if the school’s policy, explicit or not, is that 2 errors of any sort are grounds for dismissal, it is clear that there are significant implications in naming and handling errors and near misses. There has been very little published on just cultures in schools of nursing, although this trend is slowly changing. One very relevant report on the Internet describes work that has been done by the North Carolina State Board of Nursing.31 In Pilot Project, they developed a framework for reviewing practice issues, developed and offered education programs on just culture to hospitals and nursing homes, and created a Complaint Evaluation Tool to assess deviations in nursing practice and to determine what is reportable. In one very innovative approach, the University of San Francisco has created the position of Director of Quality and Safety. There is a need to prepare students for contemporary nursing practice in all of its dimensions. In addition to teaching students to be competent novice nurses, this means
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putting in place systems and structures that allow for trending and analysis of errors and near misses, and creating transparent and just cultures in which both nursing faculty and students can learn from mistakes and identify system issues that can be corrected to prevent them in the future. A key first step in transforming nursing education is creating that awareness and commitment to just culture in schools of nursing, establishing a national data repository so that a baseline can be created, and with the information generated from it, designing appropriate interventions to reduce errors and near misses. There is no universal understanding, agreement, or comfort in tracking student errors and changing the culture to become one of learning from them. Among some faculty members, there continues to be a strong belief that individual vigilance is what is required and that if an error or near miss occurs, the student is at fault. Other faculty members suggest that creating a database of errors and sharing information on their occurrence could somehow condone the commitment of errors and near misses. There is concern that if it becomes public knowledge that students are making errors, clinical facilities may be reluctant to have students from that school in their facilities. These responses are predictable and, actually, parallel the experiences of hospitals working to create systems to openly report adverse events. The IOM14 identified that to affect patient safety and error prevention, sufficient attention must be devoted to analyzing and understanding the causes of errors. Within the 6 competencies developed through the Quality and Safety Education for Nurses project to improve the quality and safety of nursing care,32 the Safety competency includes 2 skills directly related to a fair and just culture: (1) communicate observations or concerns related to hazards and errors to patients, families, and the health care team and (2) use organizational error reporting systems for near miss and error reporting. Implications for Nursing Education
There are numerous activities the schools of nursing may undertake to move to a fair and just safety culture. Engage faculty members in conversations about their views on errors and near misses Examine school policies related to student errors and analyze how they do or do not reflect the characteristics of a fair and just culture of safety Dialog with clinical partners to learn the state of their fair and just safety culture Discuss with clinical partners what they believe constitutes student errors and how they would like them to be reported and tracked Track and trend student errors and near misses to assess if there are organizational and individual considerations that may inform the curriculum
SUMMARY
At present, evidence suggests that failure to trend and track errors, and learning from them, actually increases the likelihood of other errors and near misses. A culture has to be created in both clinical settings and schools of nursing in which confidential reporting and trending of errors and near misses helps identify problems and directs action to improve system issues. This means implementing systems and structures that allow for trending and analysis of errors and near misses, and creating transparent and just cultures in which clinicians, nursing faculty and students can learn from mistakes and identify system issues that can be corrected to prevent them in the future because patients’ lives depend on it.
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