Nursing Leadership: What I Wish I’d Known Part 2

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Introduction to Debby A Renner:

Debby is one of our valued Interim Chief Nursing Officers who has worked for HTS3-Executive and Interim Recruiting for over a year. As a “permanent”; interim nursing executive, Debby is equipped with a range of experience spanning across not only stand-alone acute care to multi-facility organizations, as well as prison organizations. Her key focus areas have been on patient safety, policy and procedure development, and staff training.

“Debby is a very knowledgeable and experienced nurse leader who was immersed in a difficult and challenging situation. She skilfully engaged staff and provided candid recommendations for improvement. I highly recommend her”; – testimonial from a previous HTS3-Executive Recruiting CNO.

We are pleased to publish Part 2 in Debby’s multiple part-series blog where she shares first-hand experience as a leader in the workplace.

As a novice nurse leader faced with staff and staffing issues, I struggled with articulating that I was treating each employee equally and fairly as I coached, counselled, or consoled them. Of course, I heard the lament “Well So and So, did XYZ and it was no big deal, and then I do ABC and you are writing me up!” It was challenging to communicate to staff nurses how performance issues are not all the same and may be reviewed and handled in different ways. With a few years’ experience, I considered myself to be a seasoned nurse leader, but I had not yet discovered Just Culture.

In my initial blog I discussed rule-following and policies and procedures. Policies and procedures are the foundation for Just Culture in an organization. Fortunately, I was contracted to a large, unionized healthcare system that had fully embraced Just Culture and found Just Culture helped them articulate the fairness of the organization’s decisions to union leaders. When a patient care error, regardless of how large or small occurred, it was taken to the organizational Just Culture committee. This committee consisted of a wide variety of clinical and non-clinical leaders, who were all provided with the same Just Culture training. The committee met weekly, reviewed each error, and determined where the error fell on the Just Culture algorithm. If appropriate, the committee scheduled a second review to include an interview with the staff involved.

Upon completion of the review, the committee would determine if there were elements of staff reckless behavior (the need for discipline), staff at risk behavior (the need for coaching), or if there was a system/human error (the need for consolation). Of course, there are shades of staff accountability across the algorithm. The committee determined the course of action for dealing with staff and how system issues would be corrected. The organization had developed an algorithm that I still use to this day.

Just Culture has not been embraced by many organizations, and they continue to utilize traditional methodologies of simply identifying which individual made the error and then punishing them. That the system may have failed the nurse and thus ultimately failed the patient is not a consideration. This type of error correction does, unfortunately, allow for leadership’s capricious discrimination in the application of the punishments/remedies meted out to staff. Additionally, this type of culture encourages reporting of only those incidents that cannot be hidden. Also, organizations that have not embraced Just Culture rely on their Human Resources departments to maintain fair and equal treatment for employees. However, Human Resources oversight may not be adequate to ensure fair treatment across the board, especially when issues being investigated are of a clinical nature and require clinical judgment. So, the staff perception that one nurse is favored over another may be accurate.

In contrast to the conventional workplace, Just Culture recognizes that individual practitioners should not be held accountable for system failures over which they have no control. Just Culture also recognizes many individual or “active” errors represent predictable interactions between human operators and the systems in which they work. However, in contrast to a culture that touts “no blame” as its governing principle, Just Culture does not tolerate conscious disregard of clear risks to patients or gross misconduct, such as, falsifying a patient’s record, performing professional duties while intoxicated, intentionally disregarding organizational policies and procedures, etc., etc.

The goal of Just Culture is a culture in which front-line operators and others are not punished for actions, omissions, or decisions made by them which are commensurate with their experience and training but where gross negligence, willful violations, and destructive acts are not tolerated. Just Culture balances an environment of an open and honest reporting environment where a culture of quality learning is encouraged, with employees being held accountable for the quality of their choices. What is required is a change of focus in moving from errors and outcomes to system design and management of behavioral choices of all employees.

The previous discussion has focused on a single event error. Just Culture does provide processes for repetitive error events and repetitive at-risk behaviors. Either may lead to disciplinary action. Just Culture does not promote a blame free culture; it seeks to identify the causes of the errors and ameliorate the causes, whether individual staff related (such as reckless behavior, poor choices, or lack of training/education), or the causes are totally system driven, or the causes are combined elements of staff and system interaction.

Just Culture is a lens that allows the same focus on each error, with errors being examined using the same questions. While there is spirited discussion during the examination, the Just Culture lens keeps us focused. Over the years, I have found that staff have eagerly embraced Just Culture, as it becomes evident to them that you, as their leader, have every intention to treat them fairly.

Even if your organization has not fully embraced Just Culture, you have the choice to lead your staff through this methodology. In organizations that have not fully embraced Just Culture, I have presented the Just Culture algorithm to the staff I am charged with leading. I initiate my discussion of what Just Culture is and how the algorithm works, then we work through a few scenarios to demonstrate how the algorithm works and how it provides a lens to view patient care errors.

There are many resources available on the internet to assist you in learning more about Just Culture and how it can benefit you, your leadership, your staff, your organization and your patients.

 Boysen, P. (2013). Just Culture: A foundation for balanced accountability and patient safety. The Oschner Journal, 13(3), 400-406.
 The Just Culture Community, 2017.