The Relationship Between Just Culture, Trust, and Patient Safety

Abstract

<p><span style="text-decoration: underline;">OBJECTIVES:</span> This study explored the difference in the perception of trust between nurse leaders and direct care nurses in a Just Culture, and the impact this may have on patient safety related to voluntary reporting of patient care issues.</p> <p><span style="text-decoration: underline;">BACKGROUND:</span> Medical errors are the third leading cause of death in the United States, and nurses can have a significant impact in reducing those deaths. Hospitals are imperfect systems where nurses have competing demands, where they are forced to improvise and develop work arounds. This autonomy creates illusions that systems are effective. Direct care nurses possess the unique ability to identify errors due to their proximity to the patient. The primary barrier to reporting errors is the negative organizational response and the risk of discipline. Just Culture is an environment where organizations are accountable for the systems they design, and foster an analysis of the incident, not the individual. If nurses perceive their treatment is not just, they may drive valuable safety-related information underground. Organizations must strive to understand the nature and scope of errors, actively redesign faulty systems, and value voluntary error reporting. </p> <p><span style="text-decoration: underline;">METHODS:</span> An anonymous survey was conducted in a large, urban teaching hospital to determine the relationship of trust and Just Culture. All direct care nurses and nurse leaders (1580 participants) were recruited. </p> <p><span style="text-decoration: underline;">RESULTS:</span> This study revealed that there was a statistically significant difference between the direct care nurses’ and nurse leaders’ perceptions of trust and Just Culture within the organization. The majority of direct care nurses did not perceive that they will be given a fair and objective follow up process, or that the hospital will investigate the event fairly. When involved in an incident, direct care nurses perceived that they would be blamed, and feared disciplinary action.</p> <p><span style="text-decoration: underline;">CONCLUSIONS:</span> The findings offer practical implications to developing a trusting and Just Culture. An understanding of strengths and weaknesses can assist nurse leaders to ensure a fair and balanced approach to incident investigation. A Just Culture is not a blame-free culture, but a balanced accountability. Leaders need to look beyond the error, to the systems in which direct care nurses work, and the behavioral choices they make within these systems. When attitudes and behaviors are aligned, then the approach to performance improvement becomes the standard work of all staff. </p>