For more than a quarter of a century, Jane Barnsteiner, PhD, RN, FAAN, has dedicated her career to making patient care safer and educating nurses in safety science. Barnsteiner has served as director of nursing practice and research at Children’s Hospital of Philadelphia and director of nursing for translational research at the University of Pennsylvania Health System. She is a professor emerita for pediatric nursing, clinician educator at the University of Pennsylvania School of Nursing.
Of late, the emphasis on increasing patient safety has steered her to partner in research on examining the practice of so-called just culture in professional nursing settings and ways to translate that culture to schools of nursing across the country.
Q: What is just culture in the context of a professional or academic healthcare setting?
A: Just culture is one in which there is a trusting environment in which students and clinicians are encouraged to report errors and near-misses without fear of retribution. There are clear boundaries between acceptable and unacceptable behavior. It means there is a focus on learning and designing safe systems.
Q: How has the work of establishing just culture improved patient care, while making clinical settings better places to work?
A: Having a just culture in place means that the focus is on identifying how to improve the system, and not on the individual. It means trying to learn how an error may have taken place by examining what happened, whether it had happened before, could it happen again, what systems and structures need to be in place to make delivering care safer. Nurses and other healthcare professionals who work in organizations with a just culture do not fear retribution when they make an error or near miss, or bring a concern about an unsafe system to their leadership.
Q: How would establishing a just culture within nursing schools benefit students, faculty, patients and the clinical settings in which students may eventually work?
A: The research that Joanne Disch, RN, PhD, FAAN, professor ad honorem at the University of Minnesota School of Nursing, and I have been doing on just cultures in schools of nursing indicates that many schools of nursing have blaming cultures where the focus is on identifying the individual and providing discipline. This ultimately results in hiding errors and near misses and prevents improvement. Having a just culture within schools of nursing allows students to become socialized from the outset of their professional development to their joint responsibilities of patient care and system improvement. This serves them well when they are employed as they are well versed on understanding system vulnerabilities and the need for continuous system improvement.
Q: What can nursing schools do to better incorporate just culture?
A: Schools of nursing need to promote attitudes among faculty and students that mistakes will occur, and there is a shared accountability model that promotes individual and system learning from mistakes. A structure should be in place where there is a system of policies and processes that encourages reporting, data collection, analysis and learning essential safety-related information about errors and near misses to continuously improve care delivery or the curriculum. This approach does not excuse an individual’s reckless behavior, but acknowledges most errors have strong system elements that go beyond the performance of any one individual.
Students should be held accountable for their actions, but not blamed for system faults beyond their control. Finally, students who act recklessly may need to fail the course or be dismissed from the program, but this occurs only after a full analysis of the situation.
Q: What efforts are underway to examine the extent to which nursing schools are creating such cultures?
A: Dr. Disch and I identified that there was no information available on the extent to which nursing schools were engaged in creating just cultures. We obtained funding from the National Council of State Boards of Nursing and did a national survey of all the schools of nursing in the U.S. We found that less than 20% of schools had formal just culture systems and structures in place. Consequently we designed and piloted an electronic reporting tool to standardize reporting (Disch & Barnsteiner, 2014, Journal of Nursing Regulation), and we have established a national data repository where schools can report errors and near misses. We are currently working with the NCSBN to house the data repository. We have been sharing our results nationally at professional meetings and are heartened at the responses of faculty who are establishing just cultures in their organizations.