Just Culture: The Necessary Environment for Safe Practice Sally Watkins, PhD, RN Assistant Executive Director Nursing Practice, Education, and Research Washington State Nurses Association

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Just Culture The Necessary Environment for Safe
PracticeSally Watkins, PhD, RNAssistant
Executive DirectorNursing Practice, Education,
and ResearchWashington State Nurses Association
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Objectives

• What is a just culture?
• What steps can you take to embed a just culture
  in your work environment?
• What is WSNA doing to help establish such a
  culture of safety in the workplace?

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It is from the mission of caring for people in
times of their greatest vulnerability and need
that health care workers find meaning in their
work, as well as their experience of joy.
Lucian Leape Institute
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Yet, many suffer emotional physical harm while
providing care

• Bullied
• Harassed
• Demeaned
• Ignored
• Physically assaulted
• Physically injured

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Workplace safety is inextricably linked to
patient safety.Unless caregivers are given the
protection, respect, and support they need, they
are more likely to make errors, fail to follow
safe practices, and not work well in teams.
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Care is complexmistakesare inevitable
.
Physicians Insurance A Mutual Company
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Sowhats the old culture?

• Name, blame, shame
• Fear of retaliation, of termination
• Culture of silence
• Loss of licensure/ability to work
• Lack of administrative accountability for system
  issues
• Other?

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Characteristics of a Just Culture

• Atmosphere of trust respect
• Teamwork Have each others backs
• Encouragement for disclosure
• Learning environment
• Accountability for behaviors but not system
  failures
• Recognition that humans do make mistakes
  non-punitive response
• Leadership competency alignment

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A just culture accepts nobodys account as true
or right and others wrongInstead it accepts
the value of multiple perspectives, and uses them
to encourage both accountability and learning.
Sidney Dekker
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Differentiate

• Human error
• At risk behavior/negligence
• Reckless conduct
• Intentional rule violation
• Disciplinary Systems Theory David Marx, JD

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What steps can you take to embed a just culture
in your work environment?
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Personal Leadership
Mindfulness
Creativity
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Encouraging consciousness

• Suspend judgment
• Engage ambiguity
• Invite reflection
• Acknowledge somethings up

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Clinical Forethought

• Anticipating and preventing potential problems
• Future Think forethought about specific
  diagnoses
• Anticipation of crises, risks, and
  vulnerabilities
• Seeing the unexpected
• Benner, Hooper-Kyriakidis, and Stannard

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QSEN Competencies

• Quality Improvement
• Safety
• Teamwork and Collaboration
• Patient-centered Care
• Evidence-based Practice
• Informatics
• KNOWLEDGE SKILLS ATTITUDES

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Nurses routinely skip breaks meal periods to
provide patient care
Ann Rogers, PhD, RN, FAAN
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Self-scheduling controls

• Take your breaks
• Nourish your body
• Power naps
• Look at number of hours, shifts, days in a row
• Take your vacations

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Fatigue is a source of error

• Decreased alertness
• Decreased vigilance
• Decreased concentration
• Decreased judgment
• Depressed mood
• Impaired performance
• Increased anxiety

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Assess your fatigue risk

• Epworth Sleepiness Scale (ESS)
• The Pittsburgh Sleep Quality Index (PSQI)
• www.wsna.org Practice - Fatigue

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EPWORTH SLEEPINESS SCALE 0 would never
doze 1 slight chance of dozing 2
moderate chance of dozing 3 high chance of
dozing Sitting and reading Watching
television Sitting inactive in a public place
(e.g. a theater or meeting) As a passenger in a
car for an hour without a break Lying down to
rest in the afternoon when circumstances
permit Sitting and talking to someone Sitting
quietly after a lunch without alcohol In a car,
while stopped for a few minutes in the traffic
Johns, M.W. (1991). A new method for
measuring daytime sleepiness The Epworth
sleepiness scale. Sleep, 14, 540-545.
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Workplace engagement

• Do you know your departments quality indicators
  and result trends?
• Do you participate in debriefings? Disclosure
  processes?
• Do you attend staff meetings? Are you on a
  committee?
• DONT GOSSIP - Nothing about me without me
  philosophy re colleagues
• Provide second victim support
• Report near misses, unsafe staffing

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What else can YOU do? (WWFD)

• Moral Courage!
• Speak of up for safety using ARCC
• Ask a question
• Make a Request
• Voice a Concern (I have a concern)
• If no success, use Chain of Command

ARCC from Craig Clapper, HPI)
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WSNAs activities to promote just culture

• Proposed legislation
• Continuing education
• Resources
• Coalition partnerships

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The incentive of having a just culture is to feel
free to concentrate on doing a quality job rather
than on limiting personal liability, to feel
involved and empowered to contribute to safety
improvements by flagging weak spots, errors and
failures.
Sidney Dekker
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To find joy meaning in your daily work, you
must be able to answer YES each day

• Am I treated with dignity respect by everyone?
• Do I have what I need so I can make a
  contribution that gives meaning to my life?
• Am I recognized and thanked for what I do?

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References

• ANA Position Statement Just Culture 2010
• Barnsteiner, J. (September 30, 2011) Teaching the
  Culture of Safety. OJIN The Online Journal of
  Issues in Nursing. Vol 16, No 3, Manuscript 5.
• Benner, P, Hooper-Kyriakidis, P Stannard, D
  (2011) Clinical wisdom and interventions in acute
  and critical care. A thinking-in-action approach
  (2nd ed.) NY, NY Springer Publishing Company.
• Dekker, Sidney. (2012) Just Culture. Ashgate
  Publishing Company
• Johns, M.W. (1991). A new method for measuring
  daytime sleepiness The Epworth sleepiness scale.
  Sleep, 14, 540-545.
• Lucian Leape Institute. (2013) Through the eyes
  of the workforce Creating joy, meaning, and
  safer health care. National Patient Safety
  Foundation www.npsf.org
• NCSBN Regulatory Action Pathway. From NCQAC
  March 2013 Agenda.
• Schaetti BF, Ramsey SJ, Watanabe GC. (2008)
  Personal Leadership. Seattle, WA Flying Kite
  Publications
• The Incident Decision Tree Guidelines for Action
  Following Patient Safety Incidents
  httpwww.ahrq.gov/downloads/pub/advances/vol4/Mead
  ows.pdf