Discussion: Group Management for Just Culture
The concept of a fair and just culture refers to the way an organization handles safety issues. Humans are fallible; they make mistakes. In a just culture, ‘hazardous’ human behavior such as staff errors, near–misses and risky actions are identified and discussed openly in hopes of finding ways to improve processes and systems—not to identify and punish the individual.
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This Discussion examines the opportunities of managers in working with groups to promote change that facilitates the delivery of safe, high–quality care.
- Review the information on just culture presented in the Learning Resources.
- For this discussion, you will use the Regulatory Decision Pathway found in Russell, K. A. & Radtke, B. K. (2014).
- Examine an adverse event at the unit level in your organization or one with which you are familiar and apply the Regulatory Decision Pathway.
- Compare the findings of the Regulatory Decision Pathway to what actually happened at the unit in your organization. Was the event deemed: bad intent, reckless, at risk, or human error? According to the pathway, do you now think it was the correct action?
- Think about how a nurse leader–manager may use just culture as a framework to create or maintain a focus on accountability and outcomes throughout a group. What actions could be taken if a systems–related error was made or if an error resulted from risky behavior?
- How might role conflict and/or ambiguity have contributed to the situation?
Post a description of an adverse event in your organization and your analysis of the issue using the Regulatory Decision Pathway. Explain how role conflict or ambiguity might have influenced this situation. Apply the principles of just culture as you explain how you, as the group’s manager, would handle the situation.
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Adverse events are a part of the healthcare environment and how an event is dealt with can affect patient safety. The regulatory pathway and just culture are a means of improving the quality of care and safety culture (Russell & Radtke, 2014). Health care employees need to trust in their organization that an adverse event can be reported so that the organization and employee can learn from the event, and that it is not just a means to place blame.
An adverse event that took place in the cardiac catheterization lab was a procedure was done on the wrong patient. A patient that was to have a pacemaker instead ended up having a diagnostic catheterization. This event involved a patient identification issue by the nurse. The hospital’s patient identification policy and time out policy were not adhered to by the nurse and then the catheterization team. The incident was reported to the state, and there were several event meetings with the nurse and physician. As a result of the investigation, all staff in the catheterization lab were re-educated to the patient identification and time out policy. All staff had to sign an individual affidavit that they understood the policy. The nurse was given a written warning. This event would not have happened if the nurse and catheterization team had adhered to policy.
Regulatory Decision Pathway
Using the regulatory decision pathway, the nurse did not intend to harm the patient deliberately. The nurse asked the patient if she was Ms. X and the patient said yes. The identification policy is to check the patient’s identification band for name and medical record number against a second identifier. This was not done. There were no significant circumstances involving the system that led to the error. The nurse did not conceal the error or falsify the record. The nurse did not disregard or consciously take a substantial risk. She thought she had the correct patient. There were no similar or serious errors by this nurse. A reasonably prudent nurse would not have done the same in similar circumstances as the patient identification policy would have been adhered to. According to the regulatory decision pathway, this was at-risk behavior by the nurse (Russell & Radtke, 2014).
The catheterization team which included the physician, nurse, physician assistant, and technician contributed to this adverse event. The team did not follow the time out process policy where everything stops, and patient identification is reconfirmed with other parameters. Again, following the regulatory decision pathway, the catheterization team demonstrated at-risk behavior. At-risk behavior involves unsafe practice and carelessness which is shown by the nurse and catheterization team not adhering to policy (Russell & Radtke, 2014).
The cardiac catheterization lab is very fast-paced, and the nurses can feel the stress of the workload. The procedure area and recovery room was very busy and crowded that day. Role conflict could have contributed to the situation as there is constant pressure to keep moving. Role conflict could have contributed in the time-out process not taking place in the procedure room. Nurses have to initiate the time out process when the physician arrives, and some physicians are not very cooperative in the process. Since the adverse event, patient identification and the time out policy are strictly adhered to.
Quality improvement and work environment improvement are a part of just culture (Lockhart, 2015). Just culture is safety issues, improving processes, and not about punishing individuals (Pepe & Cataldo, 2011). As the group’s manager using the principles of culture, I would have done firm counseling stressing the significance of the incident, but as this was the nurse’s first risky behavior, I would not have done a formal written warning with the threat of being fired if it happens again. Doing a staff meeting and re-educating the policies was appropriate. Patient identification and the time out process are now part of the cardiac catheterization lab’s monthly quality assurance surveys. All new employees are well educated in the two policies and must sign an attestation that they understand by the end of orientation. This adverse event led to improved processes in the cardiac catheterization lab which is the goal of just culture (Pepe & Cataldo, 2011).
Lockhart, L. (2015). Does your organization have a just culture? Retrieved from http://www.NursingMadeIncrediblyEasy.com doi-10.1097/01.NME.0000457286.16594.92
Pepe, J., & Cataldo, P. J. (2011). Manage risk, build a just culture. Health Progress. Retrieved from http://www.outcome-eng.com/wp-content/uploads/2012/01/manage-risk.pdf
Russell, K. A. & Radtke, B. K. (2014). An evidence-based tool for regulatory decision-making: regulatory decision pathway. Journal of Nursing Regulation, 5(2), 5-9. https://class.waldenu.edu/bbcswebdav/institution/USW1/201810_27/MS_NURS/NURS_6201/readings/USW1_NURS_6201_Russell.pdf