Queen Essays

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J Nurs Care Qual Vol. 33, No. 1, pp. 1–4 Copyright c© 2018 Wolters Kluwer Health, Inc. All rights reserved.

AHRQ Commentary

This commentary on patient safety in nursing practice comes from the Agency for Healthcare Research and Quality.

The Next Frontier for Nurses Improving Quality and Safety in Primary Care

Richard Ricciardi, PhD, RN, NP

THE most common career path for en- try into the nursing profession is familiar

and well-trod: go to college, get an associate degree or a bachelor of science in nursing, and then go to work in a hospital. This is a comfortable model that we’ve been using for 60 years. Many of you followed this path or something similar to it to begin your profes- sional careers. Unfortunately, this paradigm is incomplete, given the demands of today’s evolving health care system and the complex- ity of patient care.

There remains significant need for nurses providing acute care in hospital settings. But the traditional model overlooks the grow- ing importance of having nurses at the front lines of care delivery in primary care set- tings. Nurses’ role in advancing quality and protecting the safety of patients in primary

Author Affiliation: Division of Practice Improvement, Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, Rockville, Maryland

The author declares no conflict of interest.

Correspondence: Richard Ricciardi, PhD, RN, NP, Di- vision of Practice Improvement, Center for Evidence and Practice Improvement, Agency for Healthcare Re- search and Quality, Rockville, MD 20857 (Richard [email protected]).

DOI: 10.1097/NCQ.0000000000000304

care settings is too important to consign to an afterthought.

The association between nurse staffing levels in hospitals and the quality of acute care is widely accepted.1 There is, admittedly, less quantitative evidence about the direct connection between nurses and ambulatory quality and safety. But this is an area of great interest for us at the Agency for Healthcare Research and Quality (AHRQ). As the nation’s lead federal agency for patient safety, AHRQ is highly motivated to improve safety and quality in health care wherever that care is provided. Increasingly, that place is the ambulatory setting.

Nurse practitioners (NPs) play a central role in ensuring the safety and quality of ambula- tory care. The role of the NP is well estab- lished and defined. Today, there are more than 234 000 NPs licensed in the United States, with approximately 23 000 newly minted graduates emerging every year ready to join their ranks.2 NPs can examine patients, diag- nose illnesses, prescribe medication, and pro- vide treatments. In short, NPs are equipped to provide a broad range of primary care ser- vices and lead practice improvement efforts focused on quality and safety.

In contrast to NPs, the role of registered nurses (RNs) in primary care settings is less defined. However, as primary care moves to team-based practice models to meet the needs

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1

2 JOURNAL OF NURSING CARE QUALITY/JANUARY–MARCH 2018

of Accountable Care Organizations and the Quality Payment Program, RNs are well po- sitioned to take on leading roles and new responsibilities.3 Evolving RN primary care roles, especially in high-needs patients, in- clude those of care coordinator, health coach, or health educator; furthermore, RNs can take a leadership role in the development of an in- tegrated, dynamic, person-centric care plan and make home visits.4

There are barriers, however. NPs’ scope of practice is limited in 27 states, and reimburse- ment of RNs for new models of team-based primary care is lacking. Overall, three-fifths of nurses work in hospitals, whereas only 10% of nurses work in primary or home care settings.5 The disconnect between the capa- bilities of nurses and the opportunities avail- able to them is striking.

Everything about the way health care is de- livered to patients is changing. Many of these changes have been driven by federal legisla- tion, and future developments may have an additional or even greater impact. No matter what happens, we can and should prepare for a future in which we work to help make pri- mary care practice safer and more efficient. This requires a thoughtful analysis of what tools we have (and what we lack) and what is the best and most effective use of limited re- sources to accomplish optimal outcomes for patients.

WHY NURSES?

The reality is that there is a significant gap between our nation’s demand for primary care and the number of primary care physi- cians available to meet that demand. Approxi- mately 8000 primary care physicians enter the workforce each year, but the number of pri- mary care physicians who retire each year is projected to reach 8500 by 2020.6 We already have a shortage of primary care providers, and the rate of retirement is about to outpace that of new entrants.

In a society in which our population is both growing and aging (and thus demand is increasing), this is unsustainable. A gap is

inevitable, which should translate into an op- portunity for NPs, physician assistants (PAs), and RNs. Market demands alone indicate that more patients will need to have their primary care largely overseen by an NP or a PA using a team-based approach.

Let us pause here to declare unambiguously that NPs and PAs are not replacements for physicians. This is an important distinction that needs to be stated clearly. Rather than competing with physicians, NPs, PAs, and RNs must collaborate with them as part of a com- plex, adaptive health care system in which the collective capability of the team is greater than that of a single individual.

Seminal reports by the National Academy of Medicine, the National Governors Associa- tion, and the Federal Trade Commission sup- port the importance of the role of nurses as we move to change the paradigm of health care delivery to team-based models, in which all professionals play a distinct and vital role.7-9

By capitalizing on the full potential of all health care professionals, we can optimize the goal of delivering the right care to the right pa- tient, at the right time, in the right place, by the right provider, for the right price.

AHRQ’s ROLE: WORKING IN TEAMS, ENGAGING PATIENTS

When RNs, including but not limited to NPs, work well with physicians and other health care professionals in the primary care setting, patients benefit. But we know that working in teams does not always come eas- ily. This is why AHRQ, along with the De- partment of Defense, developed TeamSTEPPS (Team Strategies & Tools to Enhance Per- formance and Patient Safety), an evidence- based curriculum to improve communica- tion and teamwork skills among health care professionals.10 Regular readers of this journal are likely familiar with TeamSTEPPS, which provides higher-quality, safer patient care by producing highly effective health care teams that optimize the use of information, people, and resources to achieve the best clinical out- comes for patients.11

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Improving Quality and Safety in Primary Care 3

A version of this curriculum, TeamSTEPPS for Office-Based Care,12 specifically addresses issues and problems unique to the ambula- tory care setting. Importantly, TeamSTEPPS courses can be taken online and for continu- ing education credits through a learning man- agement system that provides opportunities for nurses and other primary care team mem- bers to work at their own pace to obtain a TeamSTEPPS Master Trainer certificate.13

In addition to facilitating teamwork, AHRQ has several resources that promote patient and family engagement. Many of these are specific to or tailored for the office setting.14

This is important because research shows that when patients are engaged with their health care, it can lead to measurable improvements in safety and quality.

One example is the “warm handoff,” a trans- fer of care from one member of a health care team to another. Oftentimes, a nurse is in- volved. What makes it “warm” is the pres- ence of the patient and his or her family, who are there to participate in the handoff. This transparency allows patients and families to hear what is said and check for accuracy, giv- ing them the opportunity to clarify or correct information or ask questions. AHRQ’s Warm Handoff Implementation materials15 can help nurses and other primary care providers en- gage with patients in a way that will protect safety and enhance quality.

AHRQ is making available other research and tools that help make care safer in the ambulatory setting. These can be found at www.ahrq.gov/topics/ambulatory-care.html.

CONCLUSION: BACK TO THE FUTURE?

We know that primary care resources are in high demand. We also know that nurses are

uniquely positioned to meet the initial needs of large numbers of patients. However, we must confront several significant challenges that keep RNs from assuming a more active leadership role in primary care. These chal- lenges include the following: (1) most preli- censure nursing programs do not have a focus on primary care; (2) evidence is nascent on the return on investment and the full quan- tifiable value of using RNs in primary care; and (3) RNs are often viewed, shortsightedly, as a revenue drain rather than as an important contributor to primary care in a fee-for-service reimbursement environment.16

May I suggest we consider a “back to the fu- ture” approach? Decades ago, nurses in many areas were the chief providers of primary care. This was especially true in rural or inner-city areas, places that today we would call med- ically underserved communities. This prac- tice waned, especially after World War II, as medicine and hospitals evolved. There is no reason why the status quo cannot evolve once again.

Change will not be easy. It will require that we be mindful of the impact on our colleagues in the health professions, includ- ing physicians; that we make the business case for it; and that we undertake every as- pect of change with the patient at the cen- ter of the process. This final point—the im- portance of being patient-centric—is where AHRQ’s resources are so important. Primary care providers must protect the safety of pa- tients and deliver the highest-quality care pos- sible. RNs can enhance quality and safety and are well positioned to use AHRQ tools to do so. If we get this right, everyone—physicians, nurses, PAs, all members of the primary care team, and, most importantly, patients—will win.

REFERENCES

1. Needleman J, Buerhaus P, Mattke S, et al. Nurse- staffing levels and the quality of care in hospitals. N Engl J Med. 2002;346(22):1715-1722.

2. American Association of Nurse Practitioners. AANP National Nurse Practitioner Database. Austin,

TX: American Association of Nurse Practitioners; 2017.

3. Pittman P, Forrest E. The changing roles of registered nurses in Pioneer Accountable Care Organizations. Nurs Outlook. 2015;63(5):554-565.

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

4 JOURNAL OF NURSING CARE QUALITY/JANUARY–MARCH 2018

4. Long P, Abrams M, Milstein A, et al., eds. Effective Care for High-Need Patients: Opportunities for Im- proving Outcomes, Value, and Health. Washington, DC: National Academy of Medicine; 2017.

5. Smolowitz J, Speakman E, Wojnar D, et al. Role of the registered nurse in primary health care: meeting health care needs in the 21st century. Nurs Outlook. 2015;63(2015):130-136.

6. Petterson SM, Liaw WR, Tran C, et al. Estimating the residency expansion required to avoid projected pri- mary care physician shortages by 2035. Ann Fam Med. 2015;13(2):107-114.

7. Institute of Medicine. The Future of Nursing: Lead- ing Change, Advancing Health. Washington, DC: Na- tional Academies Press; 2010.

8. National Governors Association. The role of nurse practitioners in meeting increasing demand for primary care. https://www.nga.org/cms/home/nga- center-for-best-practices/center-publications/page- health-publications/col2-content/main-content-list/ the-role-of-nurse-practitioners.html. Accessed August 7, 2017.

9. Federal Trade Commission. Policy perspectives: competition and the regulation of advanced pract- ice nurses. https://www.ftc.gov/reports/policy-pers pectives-competition-regulation-advanced-practice- nurses. Published March 2014. Accessed August 7, 2017.

10. Agency for Healthcare Research and Quality. Team- STEPPS National Implementation. Rockville, MD: Agency for Healthcare Research and Quality. http://

teamstepps.ahrq.gov. Accessed July 11, 2017. 11. Brady J, Battles JB, Ricciardi R. Teamwork: what

health care has learned from the military. J Nurs Care Qual. 2015;30(1):3-6.

12. Agency for Healthcare Research and Quality. Team- STEPPS for Office-Based Care Version. Rockville, MD: Agency for Healthcare Research and Quality. https://www.ahrq.gov/teamstepps/officebasedcare/ index.html. Accessed July 11, 2017.

13. Agency for Healthcare Research and Quality. Wel- come to the TeamSTEPPS R© LMS. Rockville, MD: Agency for Healthcare Research and Quality. https://tslms.org/login/index.php. Accessed July 12, 2017.

14. Agency for Healthcare Research and Quality. Pa- tient and Family Engagement in Primary Care. Rockville, MD: Agency for Healthcare Research and Quality. https://www.ahrq.gov/professionals/quality -patient-safety/patient-family-engagement/pfeprimary care/interventions/index.html. Accessed July 12, 2017.

15. Agency for Healthcare Research and Quality. Warm Handoff: Intervention. Rockville, MD: Agency for Healthcare Research and Quality. https://www.ahrq. gov/professionals/quality-patient-safety/patient-family -engagement/pfeprimarycare/interventions/warm handoff.html. Accessed July 12, 2017.

16. Bodenheimer T, Bauer L, Syer S, et al. RN Role Reimagined: How Empowering Registered Nurses Can Improve Primary Care. Oakland, CA: California HealthCare Foundation; 2015.

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Nurs Forum. 2021;56:103–111. wileyonlinelibrary.com/journal/nuf © 2020 Wiley Periodicals LLC | 103

Received: 10 September 2020 | Revised: 28 October 2020 | Accepted: 6 November 2020

DOI: 10.1111/nuf.12525

R EV I EW AR T I C L E

Just culture in healthcare: An integrative review

Nina P. Barkell MSN, RN, ACNS‐BC | Susan Stockton Snyder MSN, RNC‐MNN

Nursing Department, Oakland Community

College, Waterford, Michigan, USA

Correspondence

Susan Stockton Snyder, MSN, RNC‐MNN,

Nursing Department, Oakland Community

College, 7350 Cooley Lake Rd, Waterford, MI

48327‐4187, USA. Email: [email protected]

Abstract

Background: In spite of two decades of the patient safety movement in the United

States, healthcare safety remains a significant problem. The paucity of empirical

literature related to Just Culture in healthcare indicates a need for this concept to

be examined and operationalized.

Purpose: The purpose was to appraise the literature regarding the use and appli-

cation of Just Culture in healthcare.

Methods: Using Whittemore and Knafl's framework for integrative reviews, a

review of the literature was conducted using Cumulative Index to Nursing and

Allied Health Literature, PubMed, PsychInfo, and Cochrane Review to identify

peer‐reviewed literature published between 2010 and 2020. The following search

terms were used: “Just Culture” AND “healthcare system” OR “health care” OR

“healthcare.”

Results: After screening for inclusion and exclusion criteria, a set of 10 articles

were included in the review. Four main themes were identified: Error Management,

Balance, Leadership and Staff, and Systems Leadership for Change.

Conclusion: There is a paucity of empirical research and quality improvement

projects focusing on Just Culture. The themes identified in this integrative review

provide the direction and focus for additional research and quality improvement

efforts that will promote the adoption of Just Culture and improvement in patient

safety.

K E YWORD S

healthcare safety, integrative review, JCAT, Just Culture, patient safety

The Institute of Medicine's (IOM) landmark report1 that up to 98,000

people die every year as a result of medical errors created the im-

petus for a radical change in healthcare. More recent reports have

estimated that patient death due to healthcare errors are as much

as four times higher than reported by the IOM.2,3 In addition to

emphasizing the need for improved patient safety culture (PSC),

the IOM report1 also recommended a shift toward a nonpunitive,

“blame‐free” culture, which recognizes the role of systems as a cause

of errors as opposed to blaming individuals.

Subsequently, the concept of Just Culture, a subculture of PSC,

emerged. Just Culture balances system and individual accountability

and is a culture in which individuals feel that they will receive fair

treatment when they report adverse events.4,5 Leape6 made a com-

pelling argument for this culture shift when he stated in testimony

to the United States Congress that the “single greatest impediment

to error prevention in the medical industry is that we punish people

for making mistakes.”

The concept of Just Culture needs to be explored and

operationalized to improve safety within the healthcare system. The

aim of this integrative review is to appraise empirical, quality

improvement (QI), and theoretical literature regarding the use and

application of Just Culture in healthcare.

1 | METHODS

Whittemore and Knafl's updated methodology7 was used as the

framework for this integrative review. This approach begins with a

clear identification of the purpose of the review and is followed by

a selection of variables of interest and the sampling frame. Data are

then evaluated, analyzed, and extracted. The final stage of data

analysis is conclusion drawing and verification.7

1.1 | Search strategy

In May and June 2020, a comprehensive search of the Cumulative Index

to Nursing and Allied Health Literature, PubMed, PsycINFO, and the

Cochrane Library was performed to identify empirical, QI, and theore-

tical literature on Just Culture in healthcare. The following search terms

were used: “Just Culture” AND “healthcare system”OR “health care”OR

“healthcare.” This search included peer‐reviewed records written in

English, published between 2000 and 2020, and focused on Just Culture.

Additional inclusion criteria were a focus on nursing and implications

for systems leadership. Quantitative and qualitative research and

evidence‐based practice projects were included. Dissertations were inclu-

ded only if the research was not published in another format elsewhere.

We excluded books and conference proceedings, research on healthcare

education, and sources that focused on PSC. The inclusion and exclusion

of all sources were based upon mutual agreement between the authors.

1.2 | Findings

Initial application of the search terms for literature in the four data-

bases published between 2000 and 2020 resulted in the retrieval of

166 articles. After the removal of 31 duplicates, 135 unique articles were

retained. We reviewed titles and abstracts, applying inclusion and ex-

clusion criteria to yield 69 articles. Due to the unexpected volume of

material retrieved, we made the decision to limit the review to articles

published between 2010 and 2020. We rescreened the abstracts of

22 records that were published between 2000 and 2009 to determine

whether they could be eliminated without detracting from the quality of

the review. If uncertain, we scanned the full‐text source to ensure that

eliminating the article would not bias the results of the integrative review.

After reading the abstracts for the remaining 47 records, 32

additional articles that did not meet inclusion criteria were elimi-

nated, resulting in a total of 15 records for full‐text review. Figure 1

outlines the search using Preferred Reporting Items for Systematic

Reviews and Meta‐Analyses guidelines.8

1.3 | Data evaluation

The 15 full‐text records were categorized as empirical studies,

reports of QI projects, or theoretical documents. Each of the 15

full‐text sources was read in their entirety by both authors.

Following the full‐text review, the dissertation9 and one of the

empirical reports10 were eliminated from data evaluation because

they did not meet inclusion criteria. Of the four remaining empirical

reports, there was no evidence higher than Level VI, using Melnyk's

hierarchy of levels of evidence.11 The remaining four primary research

reports included one cross‐sectional descriptive design,12 a qualitative

study by Freeman et al.,13 David's14 pretest posttest descriptive study,

and Petschonek et al.'s15 instrument development of the Just Culture

Assessment Tool (JCAT). All represented Level VI evidence.

The Revised Standards for Quality Improvement Reporting

Excellence (SQUIRE 2.0)16 were used to evaluate the quality of the

four QI articles. Overall, there was poor adherence to the SQUIRE

2.0 Standards.16 After quality evaluation, two QI reports17,18 were

retained for data analysis.

We evaluated the quality of the theoretical articles by examining

their primary sources and the extent to which they described the

concept. Upon full‐text review, one of these articles19 was excluded

because it was determined to be a commentary. The remaining four

theoretical articles20–23 were retained for a total of 10 records for

data analysis. This is shown in Figure 1.

1.4 | Data analysis

Data were extracted using three similar tables based upon the sub-

groups previously described (see Tables 1–3). This allowed for se-

quential data analysis that more readily identified similarities and

differences from the diverse sources.

The empirical research reports were organized for review in

Table 1. Noting the need to establish a Just Culture in healthcare,

Petschonek et al.15 developed and validated the JCAT. Two

studies12,14 reported measuring Just Culture with the JCAT. Paradiso

and Sweeney12 noted a statistically significant difference in the

perception of Just Culture of nurse leaders compared to clinical

nurses in an organization. Similarly, David14 also noted a gap in

perception of Just Culture between staff nurses and hospital ad-

ministrators before and after Just Culture training. Further, David14

reported improved JCAT scores in organizations that had a more

group‐oriented organizational culture. The fourth empirical study13

was a qualitative analysis of perceptions of nurse managers, who

identified their need for new knowledge, skills, and attitudes to fa-

cilitate the implementation of Just Culture on their units.

Table 2 displays the data for the two QI articles17,18 about the

Missouri Just Culture Collaborative (MJCC). The MJCC utilized Just

Culture training for participants in leadership roles at 67 Missouri

healthcare organizations. This collaborative offered four levels of

engagement. Both reports described the use of the Hospital Survey

of Patient Safety Culture (HSOPS)5 to measure improvement and

stated that the scores of more fully engaged participants in leader-

ship roles more closely approximated the national benchmark scores

for frontline nursing staff.17,18 These authors17,18 inferred that the

Just Culture training had therefore narrowed the perception gap

between administrators and nursing staff.

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The theoretical data are shown in Table 3. Data extracted from these

records were organized according to article purpose, concepts identified,

and implications. Three authors20–23 reviewed the components of Just

Culture and advocated for its adoption in healthcare to achieve improved

safety.21,22 On the other hand, Reis‐Dennis23 posited that Just Culture

creates a moral imbalance and that practitioners who do not follow rules

should be punished. Further, Reis‐Dennis23 advocated for a balance be-

tween prospective and retrospective approaches to accountability.

Following data extraction and display, data comparison was

performed to identify patterns, themes, and relationships. This was

done using an independent, iterative approach by both authors,

which was followed by discussion and consensus. This process re-

sulted in a color‐coded matrix of themes and subthemes. We iden-

tified four recurrent themes.

2 | RESULTS

2.1 | Error management

The first, overarching theme is Error Management. All but one of the

articles13 focused on the response to errors and advocated for robust

reporting of errors and near misses to promote learning and to drive

the development of safer systems. Nonpunitive response to errors,

communication surrounding errors, and learning from errors and near

misses were expressed as imperatives in many of the articles.12,18,20–23

Quality of the event reporting process was considered theoretically

essential to the understanding of Just Culture during the development

of the JCAT.15 Feedback and communication about events and

openness of communication are two additional dimensions of the

JCAT15 that relate to error management. Of note, the MJCC17

evaluated outcomes of the collaborative using components of the

HSOPS5 that included “nonpunitive response to error,” “frequency of

events reported,” and “feedback and communication about error.”

Marx,22 who originally developed the Just Culture model, linked the

management of errors with the intention of the individual. Further,

Marx22 advocated for accepting human error, coaching risky behavior,

and sanctioning those who recklessly, knowingly, or intentionally cause

harm. In contrast, Reis‐Dennis23 proposed that Just Culture creates a

moral imbalance by rewarding those who do not follow the rules.

2.2 | Balance

Balance was the second theme identified. Two subthemes, “balance

between fairness and blame” and “balance between system and

F IGURE 1 Preferred Reporting Items for Systematic Reviews and Meta‐Analyses7 flow diagram

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T A B L E

1 E m p ir ic al

lit er at u re

A u th o r

St u d y p u rp o se

Su b je ct s/ se tt in g

R es ea

rc h m et h o d /

va ri ab

le s/ m ea

su re s

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C lin

ic al

im p lic

at io n s

D av

id 1 4

T o ex

am in e:

n = 1 7 2

P re te st

p o st te st

d es cr ip ti ve

st u d y

R ep

o rt ed

P P R h ig h es t in

R N s;

lo w es t in

h o sp it al

ad m in is tr at o rs

U n d er ly in g h o sp it al

cu lt u re

p la ys

im p o rt an

t ro le

in w h et h er

Ju st

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tr ai n in g w ill

d em

o n st ra te

a b en

ef it

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n th e h o sp it al

o rg an

iz at io n al

cu lt u re

it s ab

ili ty

to

b en

ef it fr o m

a Ju st

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tr ai n in g p ro gr am

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ci lla

ry st af f,

an d ad

m in is tr at o rs

at tw

o

co m m u n it y fo r‐ p ro fi t

h o sp it al s

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o rg an

iz at io n al

cu lt u re

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af te r Ju st

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tr ai n in g

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o ri en

te d cu

lt u re

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d to

ad d re ss

o rg an

iz at io n al

cu lt u re

b ef o re

in tr o d u ci n g Ju st

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tr ai n in g

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al Ju st

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n

jo b cl as si fi ca ti o n an

d p er ce p ti o n o f

sa fe ty

cu lt u re

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ts : Ju st

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en t T o o l

P P R si gn

if ic an

tl y im

p ro ve

d af te r Ju st

C u lt u re

tr ai n in g in

al l jo b

cl as si fi ca ti o n s in

h ie ra rc h ic al /g ro u p ‐

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te d cu

lt u re

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re se ar ch

n ee

d s to

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p at ie n t o u tc o m es

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cu lt u re

is

co m p le x,

ca n 't ju st

sa y “w

e' re

d o in g it ”

T h e co

m m it m en

t o f m an

ag er s an

d

le ad

er s at

al l le ve

ls o f th e

o rg an

iz at io n

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e an

d re so u rc e co

m m it m en

t

n ee

d ed

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s-and-conditions) on W iley O

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A articles are governed by the applicable C

reative C om

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icense

T A B L E

1 (C o n ti n u ed

)

A u th o r

St u d y p u rp o se

Su b je ct s/ se tt in g

R es ea

rc h m et h o d /

va ri ab

le s/ m ea

su re s

R es u lt s

C lin

ic al

im p lic

at io n s

P ar ad

is o an

d

Sw ee

n ey

1 2

T o ex

am in e if th er e w as

a re la ti o n sh ip

b et w ee

n tr u st ,J u st

C u lt u re ,a

n d

er ro r re p o rt in g in

n u rs e le ad

er s

an d cl in ic al

n u rs es

n = 1 8 5

Q u an

ti ta ti ve

,

co rr el at io n al

F in d in gs : St at is ti ca lly

si gn

if ic an

t

d if fe re n ce s b et w ee

n n u rs e le ad

er s an

d

cl in ic al

le ad

er s

H SO

P S d im

en si o n s w er e co

n si st en

t

w it h JC

A T

C o n ve

n ie n ce

sa m p le

o f n u rs es

an d n u rs e le ad

er s in

in d ep

en d en

t te ac h in g

h o sp it al s in

B ro o kl yn

,N Y

C ro ss ‐s ec ti o n al

d es cr ip ti ve

d es ig n

V ar ia b le s:

Ju st

C u lt u re ,

tr u st

M o d er at el y p o si ti ve

co rr el at io n b et w ee

n

tr u st

an d Ju st

C u lt u re

R et ra in in g o f n u rs es

d o es

n o t

p ro m o te

Ju st

C u lt u re ; sh o u ld

o n ly

b e u se d w h en

th er e is

cl ea

r

ev id en

ce o f la ck

o f kn

o w le d ge

In st ru m en

ts : Su

rv ey

o f

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er s

P o si ti ve

co rr el at io n b et w ee

n tr u st

an d

vo lu n ta ry

re p o rt in g o f er ro rs

Ju st

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A ss es sm

en t T o o l

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er s n ee

d to

re sp ec t th e id ea

s o f

cl in ic al

n u rs es ,i m p ro ve

th e

sy st em

an d co

m m u n ic at e sa m e,

va lid

at es

an d en

co u ra ge

s er ro r

re p o rt in g

P et sc h o n ek

et al .1 5

T o d ev

el o p a m ea

su re

o f in d iv id u al

p er ce p ti o n s o f Ju st

C u lt u re

fo r th e

h o sp it al

se tt in g

n = 4 0 4

In st ru m en

t d ev

el o p m en

t: D ev

el o p ed

a 6 ‐s u b sc al e m ea

su re

o f Ju st

C u lt u re

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an d re lia

b le

to o lf o r m ea

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Ju st

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C o n ve

n ie n ce

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o f

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ar y h ea

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lid it y in d ex

st at is ti cs

n o t re p o rt ed

C ro n b ac h 's al p h a fo r 5 o f 6 su b sc al es

w as

> 0 .7 0

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en t re p o rt in g p ro ce ss

w as

> 0 .6 3

Se tt in g—

p ed

ia tr ic

re se ar ch

h o sp it al

C ro n b ac h 's al p h a

d em

o n st ra te d

ad eq

u at e st ru ct u re

an d re lia

b ili ty

O th er

d im

en si o n s:

tr u st ,b

al an

ce ,o

p en

‐ n es s o f co

m m u n ic at io n , fe ed

b ac k an

d

co m m u n ic at io n ab

o u t ev

en ts ,t h e

o ve

ra ll go

al o f co

n ti n u o u s q u al it y

im p ro ve

m en

t

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H SO

P S,

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o f P at ie n t Sa

fe ty

C u lt u re ; JC

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er ce n ta ge

o f p ro b le m at ic

re sp o n se s;

R N ,r eg

is te re d n u rs e.

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s-and-conditions) on W iley O

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T A B L E

2 Q u al it y im

p ro ve

m en

t re p o rt s

A u th o r

A im

/p u rp o se

P ar ti ci p an

ts /s et ti n g

In te rv en

ti o n /m

ea su

re R es u lt s

C lin

ic al

im p lic

at io n s

Sh ab

el et

al .1 8

T o im

p ro ve

p at ie n t sa fe ty

cu lt u re

am o n g p ro vi d er s

an d re gu

la to rs

P ar ti ci p an

ts in

le ad

er sh ip

ro le s

fr o m

6 7 M is so u ri h ea

lt h ca re

o rg an

iz at io n s w it h fo u r le ve

ls

o f en

ga ge

m en

t

P ro ac ti ve

,o p en

le ar n in g

m o d el ; Ju st

C u lt u re

tr ai n in g

N o d at a n o r st at is ti ca l an

al ys is re p o rt ed

O rg an

iz at io n s w h o w er e fu lly

en ga

ge d in

tr ai n in g h ad

5 0 %

ra te s o f su st ai n ab

ili ty

an d d if fe re n t re sp o n se s to

er ro rs

th an

th o se

w h o w er e le ss

en ga

ge d

H ig h es t le ve

l o f en

ga ge

m en

t

in cl u d ed

fr o n tl in e st af f

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n d p o st as se ss m en

t

ev al u at in g th e

co lla

b o ra ti ve

P ar ti ci p an

ts w er e in te re st ed

in cr ea

ti n g

ju st

cu lt u re

1 4 It em

s fr o m

H SO

P S

P at ie n t sa fe ty

aw ar en

es s in cr ea

se d

am o n g p ar ti ci p an

ts

M o re

fu lly

en ga

ge d p ar ti ci p an

ts (w

h o

w er e in

le ad

er sh ip

ro le s)

m o re

cl o se ly

ap p ro xi m at ed

H SO

P S

n at io n al

b en

ch m ar ks

fo r h o sp it al

st af f

Le ad

er sh ip

tr ai n in g in

ju st

cu lt u re

ap p ea

re d

to h av

e n ar ro w ed

th e ga

p in

p er ce p ti o n s

o n th e H SO

P S b et w ee

n ad

m in is tr at o rs

an d st af f

B ar ri er s to

su st ai n ab

ili ty

w er e co

st ,l ac k o f

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n d co

m p et in g p ri o ri ti es

V o ge

ls m ei er

et al .1 7

T o ex

p lo re

h o w

le ad

er sh ip

p er sp ec ti ve

s m ig h t b e

in fl u en

ce d b y Ju st

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tr ai n in g

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ts in

le ad

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ro le s

fr o m

6 7 M is so u ri h ea

lt h ca re

o rg an

iz at io n s, w it h fo u r le ve

ls

o f en

ga ge

m en

t

P ro ac ti ve

,o p en

le ar n in g

m o d el ; Ju st

C u lt u re

tr ai n in g

M o re

fu lly

en ga

ge d p ar ti ci p an

ts (w

h o

w er e in

le ad

er sh ip

ro le s)

m o re

cl o se ly

ap p ro xi m at ed

H SO

P S

n at io n al

b en

ch m ar ks

fo r h o sp it al

st af f

Le ad

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tr ai n in g in

ju st

cu lt u re

ap p ea

re d

to h av

e n ar ro w ed

th e ga

p in

p er ce p ti o n s

o n th e H SO

P S b et w ee

n ad

m in is tr at o rs

an d st af f

H ig h es t le ve

l o f en

ga ge

m en

t

in cl u d ed

fr o n tl in e st af f

T ra in in g w as

m o re

fu lly

d es cr ib ed

H SO

P S d at a p re se n te d w it h n o

st at is ti ca l an

al ys is

P re ‐a

n d p o st as se ss m en

t

ev al u at in g th e

co lla

b o ra ti ve

1 4 It em

s fr o m

H SO

P S p re te st

an d

p o st te st

A b b re vi at io n : H SO

P S,

H o sp it al

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o f P at ie n t Sa

fe ty

C u lt u re .

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individual accountability,” emerged consistently from the 10 records.

Marx22 described the need for balance between individual account-

ability and a nonpunitive environment. Petschonek et al.15 (p. 192)

defined balance, a subscale of the JCAT, as “one's perceptions of fair

treatment…as it relates to errors, error reporting, and its system

approach to medical error.” David14 and Paradiso and Sweeney12

used the JCAT,15 which indicates support of the inclusion of balance

in their work. Similarly, the MJCC17,18 and Freeman et al.'s study13

adopted Marx's Just Culture Framework22 for training, evaluation,

and study. Reis‐Dennis23 emphasized that balance should occur be-

tween “no blame” and individual accountability and more strongly

advocated for punishment for breaking rules. According to Marx,22

Just Culture balances individual accountability and system design.

Adelman20 stated that by adopting Just Culture, the focus is changed

from individual punishment to correcting flawed systems, adding that

individuals need to be held accountable for errors due to reckless

behavior. Finally, the need to improve systems rather than

focusing solely on individual performance was threaded through the

work of Armstrong.21

2.3 | Leadership and staff

An important theme that emerged, particularly from the empirical

and QI records, was leadership and staff. Eight of twenty‐seven items

of the JCAT directly reference employee perceptions of leaders and

administrators.15 The two empirical studies12,14 that used the JCAT

reported statistically significant differences between clinical nursing

staff and leaders with respect to perceptions of Just Culture.12,14

Freeman et al.13 supported these findings,12,14 noting that both

managers and nursing staff need to be educated regarding Just

Culture. Furthermore, commitment from managers and leaders at all

TABLE 3 Theoretical literature

Author Article purpose Concepts identified implications

Adelman20 Describe how Just Culture and technology

contribute to high reliability

Just Culture Adoption of Just Culture changes focus from

punishment of providers to fixing systems

Vigilance Need to hold individuals accountable for

errors resulting from reckless behaviorHuman errors

Error and near miss reporting

Systems issues

Armstrong21 Explore how Just Culture expands

understanding of patient safety with

recommendations for nurses

Reporting of errors and near

misses

Need to teach Just Culture principles

Fear of punishment Need to assess Just Culture in unit

System improvement

Correction of system issues Increased error and near miss reporting

indicate that nurses are actively working

to develop safety systems Individual accountability

Learning culture

Marx22 Review of Just Culture and patient safety Individual accountability Open learning culture about errors allows

correction of bad systems

Learning from errors Just Culture provides a more rational basis for

evaluating the conduct of providers

Intention of error Errors should be managed based on the

intention of the individualHuman error

At risk behavior

Reckless, intentional, knowing

violations

Link between behavioral

choices and outcomes

Accept human error; fix the system

Management of behavior Coach risky behavior

Sanction reckless, those who knowingly cause

harm, and those who intend to cause harm

Reis‐Dennis23 Identifies problems with Just Culture Model Balance backward looking and

forward‐looking accountability

Need to punish practitioners who don't follow

the rules”

Punishment Just Culture creates a moral imbalance

Respect Need just a system of punishment

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levels of the organization was needed to successfully adopt Just

Culture.13 Interestingly, Shabel and Dennis18 and Vogelsmeier

et al.17 stated that leadership training in Just Culture through the

MJCC appeared to have narrowed the gap in perceptions between

administrators and multidisciplinary staff. Unfortunately, the ad-

ministrators' scores on the HSOPS5 declined following Just Culture

training and more closely approximated the staff nurse national

benchmark.17,18

2.4 | Systems Leadership for Change

Systems Leadership for Change was the fourth theme that recurred

in the literature. Successful implementation of change begins with

good leadership24 and with a plan for sustainability.25 The findings of

this integrative review described leadership characteristics needed

to change organizational culture, challenges to implementation, and

barriers to sustainability. The importance of leadership engagement

and support was noted by Freeman et al.,13 Shabel and Dennis,18 and

David.14 Unit managers who were interviewed in Freeman et al.'s

study13 noted the complexity of Just Culture implementation. These

nurse leaders identified the need for conflict resolution skills and the

ability to engage in difficult conversations to successfully implement

Just Culture.13 David14 demonstrated that the underlying hospital

culture plays an important role in whether Just Culture training will

benefit an organization and recommended that organizational

culture be addressed before introducing Just Culture. Armstrong21

also proposed an initial assessment of Just Culture to help identify

priorities for change. Finally, Shabel and Dennis18 described a 2‐year follow up after the MJCC. The challenges to sustainability identified

in this report were competing priorities, lack of engagement, and lack

of understanding and belief in Just Culture.18

3 | DISCUSSION

A prominent finding of this integrative review was the small sample

of primary research studies. However, including QI and theoretical

literature using Whittemore and Knafl's6 integrative review frame-

work enhanced understanding of Just Culture in the context of

healthcare. The integrative review methodology6 contributes to

nursing science and informs research, practice, and policy initiatives.

This review identified four themes that were consistent across the

articles reviewed: Error Management, Balance, Leadership and Staff,

and Systems Leadership for Change. Examination of these themes

provides a stepping off point for additional research to promote the

adoption of Just Culture and improvement in patient safety.

3.1 | Limitations

There were limitations to this review. The lack of a standard defini-

tion and the use of Just Culture and PSC interchangeably14 were

barriers to screening articles by title and abstract. Limiting the search

to two keywords (Just Culture and Healthcare) and their iterations

was another potential limitation to this study. Additional variations

on the search term “Just Culture,” such as “nonpunitive response to

error,” may have provided additional relevant literature. Another

limitation was the potential for bias. The authors, both of whom are

nurses, could have introduced bias by excluding articles focused on

other health professions. The size of the nursing workforce26,27 and

the front‐line nature of the profession provided sound rationale for

this decision. The initial inclusion criterion of a 20‐year time span was

another limitation. This yielded a larger sample than was predicted.

Although the titles and abstracts were rescreened when revising the

inclusion criterion dates, it is possible that some literature may have

been excluded in error. Finally, a significant limitation was the

diversity of the sources of this review which complicated data eva-

luation, abstraction, and analysis.

3.2 | Implications

Recognizing the importance of Just Culture in promoting patient safety,

it is critical that healthcare organizations develop interventions to

improve Just Culture, increase error and near miss reporting, and im-

prove opportunities for learning. The scarcity of empirical evidence

surrounding Just Culture confounds this effort. Petschonek et al.15

recommended that the use of the JCAT be expanded to further refine

the instrument to direct resources toward improving various compo-

nents of Just Culture. This integrative review highlighted the lack of

published studies using the JCAT. The HSOPS was used to measure

dimensions of Just Culture in the MJCC.17,18 The HSOPS is a widely

used healthcare survey in the United States.5 Freeman et al.13 re-

commended more studies that compare the JCAT and subscales from

the HSOPS. However, we contend that the JCAT provides the requisite

focus on Just Culture that is essential to improve healthcare safety.

This integrative review also highlighted the lack of published

high‐quality QI projects related to Just Culture. This presents an

excellent opportunity for Doctors of Nursing Practice to lead QI

initiatives that implement Just Culture with a scholarly approach. It is

also imperative that this study be disseminated through publication

according to the SQUIRE 2.0 guidelines.16

Most importantly, this integrative review found no published

literature examining Just Culture and patient safety outcomes. The

limited empirical focus on Just Culture and its benefits may be an

underlying cause for the lack of improvement in healthcare safety in

the United States. It is critical, therefore, that more research studies

examine Just Culture, its implementation, and its relationship with

patient outcomes.

4 | CONCLUSION

Two decades after the seminal IOM report,1 the high incidence of

patient harm remains unacceptable.28 Although the HSOPS5

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provides a broad assessment of safety culture, focusing on the

measurement of Just Culture is needed to facilitate improvements

in patient safety.15 The four themes identified in this integrative

review provide the direction and focus for additional research

and QI efforts that will promote adoption of Just Culture and

improvement in patient safety.

CONFLICT OF INTERESTS

The authors declare that there are no conflict of interests.

ORCID

Susan Stockton Snyder http://orcid.org/0000-0003-0322-1178

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How to cite this article: Barkell NP, Snyder SS. Just culture in

healthcare: An integrative review. Nurs Forum. 2021;56:

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