NURS 8302 Discussion Just Culture

Just culture refers to an organization sharing the accountability for the system they have designed and how this can affect the behavior of their employees.   My current organization does not use a system of just culture when it comes to their nursing staff.   Our focus has become appeasing the patients and making sure they are happy with the services and care.   Unfortunately in certain populations the demands are never ending, and it is impossible to appease them and provide safe and quality care to them, as well as to your other patients.   The organization can be very punitive and nurses are written up for any little mishap.  This creates fear in the nurses and often causes them to focus on the wrong things;  For example:   A RN might be so focused on things getting the patient certain foods, set up in the bed right so they are completely satisfied that they might neglect another patient who has more urgent needs like getting transfused blood products or timed lab work.   Unfortunately as a NP covering the floors I come across this issue all the time.   An RN will call me for  sleep aide for a patient at 8pm and neglect to tell me their blood pressure dropped to the 80’s or that the post transfusion CBC that was due 4 hours ago has never been completed.  This punitive culture has had a great impact on the culture of safety at this institution.  Improving the culture of safety within health care is an essential component of preventing or reducing errors and improving overall health care quality PSET. ( 2019).  This system is not effective because often it causes the staff to focus on the wrong things and it also causes the staff to doubt the intuition and nursing judgment because they are so focused  on appeasing the patient.

Thanks for your educational post. This writer is of the notion that a face-to-face method is ideal for the internal dissemination of evidence-based projects. However, for an evidence-based project on diabetic education writer is of the notion that one vital external method of dissemination can also incorporate the use of technology such as the media since diabetes is a global problem in urgent need of evidence-based interventions to improve these individuals’ quality of life. The traditional news media such as newspapers, television, and radio can be an important channel for reaching practitioners coupled with the technological use of social media. The media also ensures highlights newsworthy public health issues at a particular time. Researchers are also of the notion that the media is one of the most vital means to disseminate research findings to gain policymakers’ attention.  However, when using the media for external dissemination several key factors must be taken into consideration such as the seriousness of the problem, human interest, timeline of the story, a local angel for a national or state headline, and conflict or controversy surrounding information (Ross et al., 2018).

I am a true believer that education can fix almost all problems we come across.   As a DNP prepared nurse in a institution that does not practice just culture; we can be that catalyst of change.  we can bring up these issues with upper management, along with studies and data that support Just Culture’s role in supporting patient safety and quality care.   When an institution can see how Just Culture is working in a similar setting, they might be more open to adapt it into their organizations.  As a DNP i would also collect  data during my practice ( leaving out names of nurses and patients of course ) to show the organization leaders how their punitive culture affects the practice of the RN and therefore inhibits patient safety, and often causes delay of treatment.   Again, showing the institution how their present method an actually cause a decline in patient safety and and quality care will play a vital role in getting them to adapt Just culture into their organizations also.

In a organization that already uses Just Culture; the DNP role would be to continue to support this system by participating in reviews of errors.    Supporting a environment of Just culture is multi factorial and has to include all involved from the head of the organizations and all the way down to those at the bedside.   Being an active member of these committees to see how the error occurred, where the mishap happened and how can we prevent a similar error from happening.   The DNP can also support Just Culture by speaking with the staff members involved with the error,  assessing where they went wrong and educating them as to how they could have handled them.

References:

PSNet. (2019(.  Culture of Safety Agency for Healthcare research and Quality

https://psnet.ahrq.gov/primer/culture-safety

Sample Answer 2 for NURS 8302 Discussion Just Culture

Accidents involving injuries or fatalities are frequently caused by human error. According to Quillivan (2020), those involved in accidents or errors are frequently held accountable and may face punishment to resolve the issue. Although the error is the system’s fault, it is frequently assumed that the individual is to blame. The issue would persist if the system remained unchanged and people were altered instead. According to Battard (2017), medical errors result from flawed systems, circumstances, and procedures rather than the fault of healthcare professionals. The culture of safety can be achieved in a good working environment. However, due to the persistence of harsh work situations, frontline employees in most healthcare businesses are at risk of medical errors.

Establishing a Just Culture in my organization

Healthcare organizations must be open and honest about reporting medical errors for patient safety. Transparency entails having no secrets to allow medical errors to be discussed publicly and information to flow freely (Quillivan, 2020). Furthermore, openness promotes accountability and fosters confidence when freely sharing medical errors. Therefore, a just culture is required for Transparency to occur—an atmosphere of candor and openness results from a just culture. In my organization, healthcare workers are encourage to report medical errors. For example, when a nurse commit a medical error in my organization, the case is investigated, and the nurse is send for further training. There was a case where a nurse in my unit did not follow up with the pharmacy to obtain insulin for a diabetic patient. The patient was later sent to ICU for  DKA. The nurse was sent for training and got a warning from the hospital administration. Nurses are also reported to the board of nursing, suspended or terminated for medical errors that result to fatal injury or death. While the healthcare institution owes its patients and staff a duty, everyone is ultimately accountable for their choices. Healthcare professionals should not be held accountable for systemic errors they cannot control. However, a just culture is a shared obligation that should address all medical issues in a facility (Battard, 2017). Therefore, when nurses respect safety and exercise caution when there is a threat to safety, a just culture is established.

The Role Nurse Leaders

Ensuring public safety through developing a just culture requires a shared duty between businesses and employees. Shared responsibility creates a setting where mistakes and faults can be carefully examined to promote learning (Nash, D. B., Joshi, M. S., Ransom, E. R., & Ransom, S. B. (Eds.). 2019). Establishing a culture of accountability and responsibility for patient safety is a duty and responsibility of nurse leaders. As mistakes are revealed, nurses must be held accountable and responsible to move toward a just culture. Accountability and responsibility entail determining why mistakes occur and which conditions, systems, and procedures are to blame (Quillivan, 2020). In order to prevent medical errors, nurse leaders must supervise their personnel and ensure that dangerous habits are recognized early on. As a result, nurse leaders must provide their staff members the freedom to use their abilities and expertise while still acting morally. For several eyes to spot mistakes and for everyone to feel comfortable pointing out and reporting safety hazards, hospitals must also use their workforce (Battard, 2017). In order to avoid mistakes made during work procedures, nurse leaders must collaborate with frontline nurses to find solutions through candid communication. Therefore, nurse leaders may foster an atmosphere of accountability by involving staff members in the solutions sought as problems are found.

In conclusion

A just culture arises where mistakes are openly discussed to ensure patient safety. Transparency helps staff members and nursing leaders spot and fix systemic problems that could cause medical errors and avert harm. As a result, a just culture is a shared responsibility that should handle every medical issue in a healthcare facility. However, healthcare professionals should be held accountable for preventable errors.

References

Battard, J. (2017). Nonpunitive response to errors fosters a just culture.Nursing Management,48(1),55https://journals.lww.com/nursingmanagement/FullText/2017/01000/Nonpunitive_responhttps://journals.lww.com/nursingmanagement/FullText/2017/01000/Nonpunitive_response_to_errors_fosters_a_just.12.aspx

Marx, D. (2019). Patient safety and the just culture.Obstetrics and Gynecology Clinics,

46(2),239-245. https://www.obgyn.theclinics.com/article/S0889-8545 (19)30004-X/fulltext

Nash, D. B., Joshi, M. S., Ransom, E. R., & Ransom, S. B. (Eds.). (2019).The healthcare quality

book: Vision, strategy, and tools (4th ed.). Health Administration Press

Quillivan, R. R. (2020).Just Culture in Healthcare Error Management: Nurse-in-Training View of Just Culture and Outcomes of Event Involvement(Doctoral dissertation,University of Memphis).https://www.proquest.com/openview/4d4ab5161676c4e084c1a19b773c34e0/1?pqorigsite=gscholar&cbl=51922&diss=y

Sample Answer 3 for NURS 8302 Discussion Just Culture

Your discussion on the concept of Just Culture in healthcare is insightful and highlights the importance of fostering an environment that promotes learning from mistakes rather than blaming individuals. Your emphasis on the systemic nature of medical errors and the need to address flawed systems, circumstances, and procedures aligns with current perspectives on patient safety.

Your example of how medical errors are addressed in your organization, where nurses are sent for further training after committing an error, illustrates a commitment to learning and improvement rather than punitive measures alone. The emphasis on investigating cases and providing additional training reflects a proactive approach to addressing root causes and preventing future occurrences.

The role of nurse leaders in establishing a Just Culture is crucial, as you rightly point out. Your emphasis on shared responsibility, accountability, and transparency emphasizes the collaborative effort required to create an environment where mistakes can be openly discussed for the sake of patient safety. The involvement of nurse leaders in supervising staff, promoting accountability, and encouraging open communication contributes to the overall culture of safety.

Your conclusion aptly summarizes the key points, highlighting the need for open discussions about mistakes to ensure patient safety, the importance of transparency in spotting and fixing systemic problems, and the shared responsibility in fostering a Just Culture. Your insights contribute to the ongoing dialogue on patient safety and quality improvement in healthcare.

References

Baarle, E. van, Hartman, L., Rooijakkers, S., Wallenburg, I., Weenink, J.-W., Bal, R., & Widdershoven, G. (2022, August 13). Fostering a Just Culture in Healthcare Organizations: Experiences in Practice, BMC Health Services Research, BioMed Central

https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-022-08418-zLinks to an external site.

Panagioti, M., Khan, K., Keers, R.N., Abuzour, A., Phipps, D., Kontopantelis, E., Bower, P., Campbell, S., Haneef, R., Avery, A.J., & Ashcroft, D.M. (2019). Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l4185Links to an external site.

Sample Answer 4 for NURS 8302 Discussion Just Culture

Your thoughtful assessment of the role of DNP-trained nurses in creating a just culture within healthcare organizations provides crucial insight. Thus, building upon your points, it is imperative to emphasize their proactivity when responding to errors and preventing future incidents.

I agree that DNP-prepared nurses are uniquely poised to act as intermediaries between frontline healthcare delivery and systemic policy-making. Leveraging their advanced education in clinical practice, leadership, and system management, DNP nurses can utilize evidence-based practices that reduce errors(Marx, 2019). Not only should immediate issues related to errors be addressed directly, but root cause analyses must also be undertaken in order to fully comprehend how such errors arise in the first place.

You mentioned that “education and mentoring staff is paramount, and DNP-prepared nurses play a crucial role in this.”By creating an atmosphere where mistakes are welcomed rather than punished, these DNP nurses can foster a culture of continuous improvement that aligns with just cultural principles (Paradiso & Sweeney, 2019). Here, the focus should be on understanding why errors occurred and improving systems rather than solely assigning blame to individuals. DNP-prepared nurses can set an excellent example in encouraging open communication and transparency within an organization by creating safe spaces where staff members can report errors and near misses without fear of reprisals. Ultimately, this canstrengthen the organization’s safety culture.

Based on your discussion, it is evident that DNP-prepared nurses play a critical role in creating and supporting a just culture by not simply managing errors. Their role encompasses proactive engagement in risk assessment, staff education, system enhancement, and creating an atmosphere conducive to open communication and learning (Paradiso & Sweeney, 2019). Their holistic approach addresses existing issues and preemptively mitigates potential threats that threaten patient safety and care quality.

References

Marx, D. (2019). Patient safety and the just culture. Obstetrics and Gynecology Clinics, 46(2), 239-245.https://doi.org/10.1016/j.ogc.2019.01.003

Paradiso, L., & Sweeney, N. (2019). Just culture: It’s more than policy. Nursing management, 50(6), 38.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6716556/