Discussion 2: Just Culture

Just Culture is a process of allocating responsibility for events, that is, what is caused by the system, and what is caused by the human component (Barkell & Snyder, 2020). Just Culture strikes a balance between punishment and blamelessness (Rogers et al., 2017). It focuses on the differences between human error, at-risk behaviors, and reckless behavior and assigning justice based on the quality of choice made by the individual (Barkell & Snyder, 2020). It is a balancing system and individual accountability to best support quality, safety, and organizational values. In general, it fosters an environment of openness and fairness to facilitate reporting of errors (Rogers et al., 2017).

Nursing leader’s server as advocates within their organizations. Leaders have requisite knowledge, skills, and understanding and represent the front door into the healthcare service delivery. Nursing leaders need to be comfortable withing their administrative structures to use their powers to advocate for the role of nurses. Advocating in policy discussions to help reduce health care cost and improvement in patients’ outcomes and quality of life through collaborative team-based care. (Stevenson, 2021) Advocating for nursing staff can begins with assessing needs. Do the nurses have the correct tools they need to provide best practice care. Are nurses being treated fairly and are they assuring measures to prevent nursing fatigue and burn out such as appropriate breaks and lunches.

Explanation of whether my Organization Uses a Just Culture

My organization transitioned to a just culture several years ago where colleagues are encouraged and supported to do the right thing. It is a culture that promotes open and honest discussions when errors occur. Frontline staff is included in root cause analysis meetings to discuss adverse events and identify opportunities for improvement. A consistent review process of behavior and action is utilized. My organization believes it is essential to learn from our mistakes and improve procedures and policies to impact quality, safety, and patient care positively. My organization’s culture is to be fair and work with colleagues to be better.

Doctor of Nursing Practice (DNP)-Prepared Nurses Role

The role of the DNP-prepared nurse in promoting a just culture environment is a commitment to safety throughout the organizations (PSNet, 2019). The DNP-prepared nurse must strive for consistent and safe operations. This week’s learnings identified four common themes in a just culture in healthcare.

For the DNP-prepared nurse, it is essential to encourage reporting errors to identify opportunities and seek solutions, achieve a balance in accountability and fairness, ensure leaders are committed and educated on just culture (Barkell & Snyder, 2020). Ultimately it must be an organizational priority (Barkell & Snyder, 2020). Leading by example and ongoing review of the critical components of a just culture with leadership and staff is an example of supporting a just culture environment. Just culture in healthcare aims to manage the behavioral choices of individuals, improve system design, and provide quality, safe patient care.

References

Barkell, N. P., & Snyder, S. (2020). Just culture in healthcare: An integrative review. Nursing Forum, 56(1), 103–111. https://doi.org/10.1111/nuf.12525

PSNet. (2019). Culture of safety. Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/primer/culture-safety

Rogers, E., Griffin, E., Carnie, W., Melucci, J., & Weber, R. J. (2017). A just culture approach to managing medication errors. Hospital Pharmacy, 52(4), 308–315. https://doi.org/10.1310/hpx5204-308

 

Brief description of any previous experience with quality and safety.

Throughout my professional nursing career, I have worked indirectly with quality and safety until recently.  As a previous Systems Infection Preventionist (SIP) for a large teaching Magnet certified health care system, quality and SIP teams worked closely to improve care and patient safety by decreasing hospital acquired infections (HAIs), such as CLABSIs, CAUTIs, post-operative infections, and staff COVID exposures. The main quality indicator used to minimize hospital infections were surveillance of hand hygiene practices throughout the system.

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Each month, quality and SIPs would come together to review and discuss the Standardized Infection Ratio (SIR) for the above HAIs.

The SIR statistic would be used to compare the actual number of HAIs over time to the predicted number of infections. I recall department heads from all nursing units, medical directors, and quality and IP directors meeting on a weekly basis to determine why CLABIS and CAUTI infections were continuing to increase throughout the system. New health care practices and policies would be initiated, followed by use of the PDSA quality improvement model to determine outcome or decrease in HAIs, or the need for revision of policy or health care practices.

The SIP role gave me a closer look  QI processes. However, there is so much more to learn and I am looking forward to gaining a better understanding on the when and why of QI processes, along with the appropriate metrics to use to improve patient outcomes.

How the role as the DNP-prepared nurse represents a function of quality and safety for nursing practice and healthcare delivery. Be specific and provide examples.

Before responding to this question. I had to reflect on my professional journey, healthcare gaps noted in patient outcomes and leadership practices, advance technology of interest that can educate and improve patient outcomes, and development of professional nursing skill sets required to meet a need.

After careful reflection and experiences, the DNP-prepared nurse will represent a function of quality and safety for nursing practice and healthcare delivery through involvement, collaboration, and networking with other team leaders, thus giving one a sense of confidence in creating those forums that will elicit needed conversations and participation in promoting change. For example, the organizational, economic and leadership skills of a DNP-prepared nurse can position one to become the voice of change at the executive level. Becoming an HCO board member can lead those processes that will promote a systems-based approach to quality and safe clinical practice (Sigma Repository, 2020).

As a DNP-prepared nurse, my goal would be to advocate for those changes that will improve quality outcomes by (1) creating an environment of recruitment and retention of competent staff, (2) promoting a mindset and culture for learning and innovativeness, (3) establishing expert skills that focuses on evaluating, translating, and disseminating research into practice for the benefit and improvement of patient outcomes, and (4) leading change through advocacy of health care policy that promote quality and patient safety.

For example, selecting a Virtual reality – Second Life advance technology system to establish an education program that will educate staff on research, implementation, and evaluation of those evidence-based practices that will improve quality and promote safety.

Sigma Repository. (2020). The expert role of the DNP prepared nurse impacting healthcare systems: Bench to bedside, classroom to boardroom. Retrieved from http://hdl.handle.net/10755/2114

Great Post. I agree with you that the DNP prepared nurse is great position to function as an change agent. Our expanded body of knowledge provided us the the ability to make changes not only from an superficial level, but from a executive stand point.  With a foundation and understanding of evidence based- practice we can improve education, re-vamp policy and procedures, and stand in the gap of knowledge deficits.  The sources of data for quality improvement are vast.  Key factors to consider are the reason why a change in need and how will this change make the environment better for the staff and the patients.  In an article by Cleveland and Smith (2019) they discuss how nurse usually respond to change innovative and professional responsibility.  DNP nurses will continue to transform health care and stakeholders understand of quality care initiatives.  It is a great time for DNP nurses to use their knowledge base to engage in disciplinary perspectives, patient/staff advocacy, advanced policy research and continuum of evidence based and patient centered outcomes (Cleveland &Smith, 2019).

 

Reference:

Cleveland, K., Motter, T., & Smith, Y. (2019). Affordable care: Harnessing the power of nurses. OJIN: The Online Journal of Issues in Nursing, 24(2). https://doi.org/10.3912/ojin.vol24no02man02

Nash, D. B., Joshi, M., Ransom, E. R., & Ransom, S. B. (2019). Overview of Healthcare quality. In The healthcare quality book: Vision, strategy, and tools (p. 33). essay, Washington, DC.

 

According to Eng and Schweikart (2020), just culture is a trusting environment in which healthcare personnel is supported and treated fairly when something goes wrong with patient care. Consider the situation in which a nurse discovers that a colleague will give a patient the incorrect medicine dose. She realizes that the drug has been administered before she gets to the patient’s room. She calls the coworker outside to speak with him and informs him that the dosage is incorrect. They debated it and agreed that if medication to prevent an overdose reaction is not given, the patient will most likely face serious side effects. Despite their fear, they gather the courage to inform the in-charge doctor.

The doctor acts promptly and finds a way to stabilize the patient’s health before any catastrophic effects arise. The nurses are then brought to a meeting to discuss how to avoid such incidents in the future and the steps to follow. They are also reminded of the numerous drugs administered in the hospital. The management decides to implement a training matrix that requires employees to attend seminars and workshops to refresh and improve their healthcare knowledge. Employees are encouraged to report any medication delivery errors that could put a patient at risk.

Consider the case where a nurse picks the wrong drug from the dispensing system and gives it to a patient. The patient is in a condition of shock because of the medicine. The nurse is perplexed when she realizes her mistake. She is afraid of losing her work if she reports the incident. The patient dies, and the truth is only found after a postmortem. Even though the nurse is summoned and accepts responsibility for her error, she is fired. Openness, universal and reciprocal accountability, patient-centered care rather than doctor-centered care, perceiving errors as system failures rather than individual faults, and encouraging teamwork are all features of a just culture (Eng & Schweikart, 2020).

In the first scenario, the nurses are entirely transparent. Their decision to tell the truth resulted in saving a life and the improvement of the hospital’s standards. The nurse’s choice in the second case resulted in the death of a patient. He lost his job. If he had followed the correct procedures, she could have saved a life, other people would be motivated to speak up if they made a mistake, and the hospital would have learned from the error and made changes as a result.

Reference

Eng, D., & Schweikart, S. J. (2020). Why accountability sharing in health care organizational cultures means patients are probably safer. AMA J Ethics, 22(9), E779-783. Doi: 10.1001/amajethics.2020.779.