Requirements for implementing a 'just culture' within healthcare organisations: an integrative review

Reconciling Safety and Safeguarding in Health and Social Care: Implications for Just Culture

Facilitating a just response to staff involved in patient safety events is complex, with varying perceptions of safe behaviour and practice across settings. This viewpoint paper explores the challenges of developing a just culture, particularly in safeguarding situations involving peer-to-peer harm. It argues that established just culture principles, such as balancing staff and organisational accountability and using After Action Review (AAR) debriefs, need to be tailored to these contexts. In particular, organisational accountability is paramount in safeguarding situations, especially where individuals do not have the capacity to understand or intend their behaviours. Furthermore, AARs are inappropriate incident responses for serious aggression, violence, and abuse cases. To counter this, a consistent AAR practice can be valuable for preventative learning when applied to the service user care journey and comprehensive incident learning responses. The incorporation of social workers, service users, and families can help promote learning and the prevention of events. Finally, this paper emphasises the need for consistency in core safety principles across settings and the need to tailor just cultural principles to particular contexts. Future research on the role of AAR in diverse settings is recommended.

The '5 Moments for Hand Hygiene': casting a critical eye on the implications for practice

The '5 Moments' approach is a time-space framework that delineates when hand hygiene should be performed and provides a resource for educators and auditors. It has become the dominant paradigm for organisations, practice, policy, and research in relation to hand hygiene. It is a concept that adopts the 'precautionary principle' that if the relative risk of a specific care task is unknown, a safe system must be to treat them on an equal level. However, a literal interpretation will frequently result in an extraordinary, implausible number of hand-hygiene opportunities and if this then becomes the standard to audit practice, within a policy document that espouses zero tolerance, it is likely to generate inauthentic data. If used effectively the 5 Moments concept provides an opportunity to enhance practice and reduce healthcare-associated infections but the healthcare provider organisation must embody a 'just culture' and collect the data in a climate of openness, transparency, and learning.

Methods of detection of adverse events in critical care: a protocol for a systematic review

INTRODUCTION

Adverse events, defined as unintended patient harm contributed to by healthcare, continue to increase morbidity, mortality and cost. Critically ill patients are at high risk of adverse events; however, the optimal approach to detection in this setting is unknown. Numerous approaches have been used, including voluntary reporting, chart reviews and trigger tools. The objective of this systematic review is to gain insight into the capacity of individual methods to detect adverse events in the intensive care unit (ICU), to inform implementation, and to facilitate quality improvement.

METHODS AND ANALYSIS

Ovid MEDLINE, Ovid EMBASE, CINAHL, the Cochrane Library and Google Scholar were searched on 2 October 2023 for randomised controlled trials and observational studies evaluating the implementation or ongoing use of one or more systems of detection of adverse events in ICUs (neonatal to adult). Outcomes will include the total number of adverse events identified by detection method per 100 patient days (primary outcome), categories of adverse events, associated harm and whether detection informed quality improvement. A risk of bias assessment will be performed. The results will provide insight into each method's capacity to detect adverse events in addition to their associated severity.

ETHICS AND DISSEMINATION

Ethics approval was not required as patient data will not be collected. A manuscript will be submitted to a peer-reviewed scientific journal.

PROSPERO REGISTRATION NUMBER

CRD42024466584.

How Doctors Talk About Medical Errors: A Qualitative Study of Junior Doctors' Experiences

During the last three decades, an increased amount of research on errors in health care has been conducted. Studies show that physicians find it challenging to handle errors because of the blame and guilt that errors cause. Communicating with colleagues has been identified as vital for coping with errors and for creating a just culture; however, many physicians do not usually discuss their errors. Knowledge about how junior doctors experience errors is vital to ensure that they both receive emotional support and learn from errors. To capture junior doctors' perceptions and experiences, we used a qualitative, exploratory design based on virtual focus groups. We conducted seven virtual focus groups with 22 junior doctors from 11 specialties. We defined three main themes: (1) how the junior doctors conceptualized medical errors, (2) how they experienced talk about errors among colleagues, and (3) the context in which this talk took place. The participants experienced errors as challenging elements in their working life; however, they struggled to define it. They described inconsistencies regarding the reasons for discussing errors within the learning environment, with some being experienced as constructive (providing education and support) and some as destructive (involving blame and shame). There was a discrepancy between the wish to normalize error and the lack of sharing between colleagues. Our study shows that error in health care is a complex phenomenon that challenges junior doctors' navigation in clinical practice. Despite efforts to implement an open and just culture, this has not yet been achieved.

Restorative Just Culture: An Exploration of the Enabling Conditions for Successful Implementation

BACKGROUND/OBJECTIVES

Restorative responses to staff involved in incidents are becoming recognized as a rigorous and constructive alternative to retributive forms of 'just culture'. However, actually achieving restoration in mostly retributive working environments can be quite difficult. The conditions for the fair and successful application of restorative practices have not yet been established. In this article, we explore possible commonalities in the conditions for success across multiple cases and industries.

METHODS

In an exploratory review we analysed published and unpublished cases to discover enabling conditions.

RESULTS

We found eight enabling conditions-leadership response, leadership expectations, perspective of leadership, 'tough on content, soft on relationships', public and media attention, regulatory or judicial attention to the incident, second victim acknowledgement, and possible full-disclosure setting-whose absence or presence either hampered or fostered a restorative response.

CONCLUSIONS

The enabling conditions seemed to coagulate around leadership qualities, media and judicial attention resulting in leadership apprehension or unease linked to their political room for maneuver in the wake of an incident, and the engagement of the 'second victim'. These three categories can possibly form a frame within which the application of restorative justice can have a sustainable effect. Follow-up research is needed to test this hypothesis.

Unravelling clinicians' shared decision-making adoption: a qualitative exploration through the lens of diffusion of innovations theory

OBJECTIVES

This study uses the diffusion of innovations (DOI) theory to comprehensively understand the adoption of shared decision-making (SDM) in clinical practice, specifically focusing on the 'knowledge' and 'persuasion' stages within DOI. We aim to understand the challenges and dynamics associated with SDM adoption, offering insights for more patient-centred decision-making in healthcare.

DESIGN

This qualitative study employs a modified framework analysis approach, integrating ethnographic and interview data from prior research, along with additional interviews. The framework used is based on the DOI theory.

STUDY SETTING AND PARTICIPANTS

This study was conducted in the obstetrics and gynaecology department of a tertiary teaching hospital in the Eastern region of the Netherlands. It included interviews with 20 participants, including gynaecologists, obstetrics registrars and junior doctors currently practising in the department. Additionally, data from prior research conducted within the same department were incorporated, ensuring the maintenance of contextual consistency.

RESULTS

Findings reveal a complex interplay between SDM's benefits and challenges. Clinicians value SDM for upholding patient autonomy and enhancing medical practice, viewing it as valuable for medical decision-making. Decision aids are seen as advantageous in supporting treatment decisions. Challenges include compatibility issues between patient and clinician preferences, perceptions of SDM as time-consuming and difficult and limitations imposed by the rapid pace of healthcare and its swift decisions. Additionally, perceived complexity varies by situation, influenced by colleagues' attitudes, with limited trialability and sparsely observed instances of SDM.

CONCLUSIONS

Clinicians' decision to adopt or reject SDM is multifaceted, shaped by beliefs, cognitive processes and contextual challenges. Cognitive dissonance is critical as clinicians reconcile their existing practices with the adoption of SDM. Practical strategies such as practice assessments, open discussions about SDM's utility and reflective practice through professional development initiatives empower clinicians to make the best informed decision to adopt or reject SDM.

Building a NICU quality & safety infrastructure

The American Academy of Pediatrics (AAP) Standards for Levels of Neonatal Care, published in 2023, highlights key components of a Neonatal Patient Safety and Quality Improvement Program (NPSQIP). A comprehensive Neonatal Intensive Care Unit (NICU) quality and safety infrastructure (QSI) is based on four foundational domains: quality improvement, quality assurance, safety culture, and clinical guidelines. This paper serves as an operational guide for NICU clinical leaders and quality champions to navigate these domains and develop their local QSI to include the AAP NPSQIP standards.

Assessment of nurse's perceived just culture: a cross-sectional study

BACKGROUND

The non-punitive approach to error investigation in most safety culture surveys have been relatively low. Most of the current patient safety culture measurement tools also lack the ability to directly gauge concepts important to a just culture (i.e. perceptions of fairness and trust). The purpose of this study is to assess nurses' perceptions of the six just culture dimensions using the validated Just Culture Assessment Tool (JCAT).

METHODS

This descriptive, cross-sectional study was conducted between November and December 2020. Data from 212 staff nurses in a large referral hospital in Qatar were collected. A validated, self-reported survey called the JCAT was used to assess the perception of the just culture dimensions including feedback and communication, openness of communication, balance, quality of event reporting process, continuous improvement, and trust.

RESULTS

The study revealed that the overall positive perception score of just culture was (75.44%). The strength areas of the just culture were "continuous improvement" dimension (88.44%), "quality of events reporting process" (86.04%), followed by "feedback and communication" (80.19%), and "openness of communication" (77.55%) The dimensions such as "trust" (68.30%) and "balance" (52.55%) had a lower positive perception rates.

CONCLUSION

A strong and effective just culture is a cornerstone of any organization, particularly when it comes to ensuring safety. It places paramount importance on encouraging voluntary error reporting and establishing a robust feedback system to address safety-related events promptly. It also recognizes that errors present valuable opportunities for continuous improvement. Just culture is more than just a no-blame practice. By prioritizing accountability and responsibility among front-line workers, a just culture fosters a sense of ownership and a commitment to improve safety, rather than assigning blame.