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Nursing Management:
doi: 10.1097/01.NUMA.0000419492.49675.25
Feature: Magnet(R) Excellence

Forging a new culture: Blending Magnet® principles with Just Culture

Bashaw, Erin Shannelle DNP, RN; Lounsbury, Karen DNP, RN

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At ValleyCare Health System in Pleasanton, Calif., Erin Shannelle Bashaw is a medical-surgical nurse and Karen Lounsbury is the director of Staff Development and Nursing Education.

The authors have disclosed that they have no financial relationships related to this article.

The quest for Magnet® recognition and Just Culture is distinctively desirable in an industry fraught with risks, mistakes, and fatal errors. Achieving Magnet recognition means that an organization has created an infrastructure of interdisciplinary care that successfully integrates best practice, promotes the highest-quality care, and produces unprecedented patient care outcomes while promoting collaboration and shared decision making.1 The theory of Just Culture advances critical organizational examination of early possible error discovery and error reporting in an attempt to mitigate system failures to create the safest possible working environment. Fusing Magnet recognition and Just Culture focuses on creating the safest healthcare system through disclosure, transparency, and public reporting. Building a new culture through the blending of Magnet principles and Just Culture ideology is the future of dynamic, adaptive, creative, and innovative healthcare systems.

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Understanding Just Culture

Just Culture is a relatively new model for the healthcare industry, but it isn't a new concept. The theory of Just Culture was originated by James Reason in response to devastating events that occurred in three industries riddled with risk: the military, air traffic control, and nuclear power plants.2 Reason describes these highly reliable and dynamic organizations as being influenced by external and internal forces that are constantly changing, under intense time constraints, with relatively few negative outcomes despite the likelihood of great catastrophe.

Just Culture propels transparency into the forefront of healthcare by straddling the great divide between punitive error reporting systems and blame-free error reporting systems.3 Creating a Just Culture promotes disclosure of all healthcare errors through collaboration, proportional accountability, intense self-evaluation, and decency.4 Just Culture promotes organizational learning by accepting that mistakes will happen, creating accountability by identifying behaviors that inherently expose organizations to risk, and building resilience by promoting industry safety.

There are three types of behaviors that contribute to errors: human error, at-risk behavior, and reckless behavior. Human error happens unintentionally and without malintent. At-risk behavior consists of acts that are designed to cut corners and save time, despite the known but seemingly justified danger. Reckless behavior consists of acts that disregard all safety measures.3

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Organizations that adopt the Just Culture model accept that errors occur with and without negative outcomes. Each type of error is equally important to disclosure by those involved because the act of error identification and reporting builds trust, transparency, quality care, and patient safety. Just Culture embraces system failures, errors, and weaknesses for the purpose of turning them into educational opportunities for improvement and learning.5

Other industry experts have expanded the concept of Just Culture. One expert argues that each person should be held accountable for his or her errors, and thorough examination of the error is essential to determine the individual's level of responsibility, expanding the concept of Just Culture to include a fourth domain of accountability: knowing violation.6 Those who participate in this type of behavior knowingly do so at the risk of patient safety and have no regard for safety itself.6 Another expert argues that there's a necessity to identify individual accountability and responsibility for patient safety and a need to develop a systematic response to a healthcare culture of safety.7

Changing current practice and ideology isn't without its challenges. Magnet principles and Just Culture ideology must be synonymous with the goals, vision, and mission of the organization. Just Culture should be promoted and demonstrated by all levels of an organization. Implementing a Just Culture that includes and expects disclosure and reporting from all employees creates trust within a healthcare system, which will help eliminate the barriers to disclosure that include fear of punitive action by leadership, retribution from senior leadership and fellow coworkers, criminalization of errors, and social isolation from colleagues.8 According to one study, 40% of clinicians were too intimidated to report errors, and nonclinicians were more likely to report errors than frontline caregivers.9,10

Just Culture isn't a nonpunitive error reporting system and in no way negates the responsibility of the caregiver's accountability or organizational liability. Adopters of Just Culture recognize that errors need serious investigation and critical evaluation of facts.4 Counseling, remediation, termination, and possible criminalization of errors aren't removed from this theory.11 Just Culture seeks to promote organizational commitment to universal safety in healthcare by increasing awareness, error reporting education, performance, and industry compliance.12 Additionally, Just Culture helps prevent errors by looking forward and anticipating when and where errors may occur and how they can be prevented.

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Translating Just Culture into Magnet® readiness

Structural empowerment showcases organizational structure, personnel policies and programs, community engagement, images of nursing within the organization, and professional development.13 Magnet Recognition is granted to organizations that create an infrastructure of collaboration among all staff members and foster a culture of shared decision making. According to one article, nurses reported feeling empowered, more satisfied with their work, more able to contribute to the organization as a whole, and more likely to report problems when related to quality of care issues in hospitals that are able to make the “links” between structural empowerment, Magnet, and a culture of safety.1 Additionally, nurses who felt supported and empowered by their managers and organizations were more likely to stay at their current place of employment.14

Exemplary professional practice discusses professional models of care, uses of consultation and resources, autonomy within the organization, nurses as teachers, and interdisciplinary relationships.13 Just Culture has the potential to increase retention rates for hospitals; reinvent nurse administrators through a deeper understanding of transparency, disclosure, and public reporting; and establish the foundation for the transformation of nurse satisfaction. Not only does it promote personal development through critical self-evaluation and mastery of awareness, but it can also create better opportunities for achieving Magnet recognition and quality of patient care.15 One of the major considerations for attaining Magnet recognition is direct care nurse retention rates.16 Nurses who feel compelled to promote safety and organizational unity are likely to stay at their current place of employment. Additionally, morbidity and mortality are lower at Magnet facilities because they tend to employee nurses who are more experienced with higher levels of education and have less turnover of nursing staff.17

Transformational leadership displays the quality of nursing leadership and management style of the organization.13 Leadership skills and management styles influence all aspects of nursing care because of the amount of time nurse managers and nurse administrators spend with frontline nurses and their ability to empower and engage staff. One study reported that an employee's opinion of his or her nurse manager or supervisor had greater impact on their intent to stay with an organization than their satisfaction with the organization itself.18 Another study, conducted in Australia, reported that the morale of nurses was greatly influenced by the nurse administrator and had a huge impact on retention, turnover, workplace health, and quality of care and safety issues.19 Nurse administrators must have substantial knowledge of their organization to create opportunities for change and enhance programs and processes that create a culture of shared governance and commitment.20

New knowledge, innovation, and improvements demonstrate organizational commitment to quality improvement.13 New knowledge is one of the biggest benefits of Just Culture. Exposing errors, mistakes, and weaknesses within the patient care domain and healthcare systems promotes opportunities for the entire organization to learn for the purpose of creating positive patient outcomes. Just Culture cultivates innovation and improvements by investigating errors and designing systematic efforts to prevent future ones. Innovation involves risk, creativity, and trust that those doing a particular job understand the nature of the activities most intimately and are uniquely able to identify areas of improvement.

Empirical outcomes demonstrate the quality of care within an organization translated through numerical data.13 Empirical outcomes are supporting data that hospitals and healthcare system collect over many years to prove that they've achieved the required elements for Magnet recognition. Additionally, numerical data help identify the strengths and weaknesses of various programs, core measures, and initiatives within an organization. This information is significant for national benchmarking and reveals areas of success and areas for improvement.

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Blending cultures

Blending Magnet principles and Just Culture ideology isn't a simple task. An organizational assessment must be completed to determine if the infrastructure is ready to support the dynamic and evolutionary change. All staff members must be educated about the guiding principles of Magnet recognition and Just Culture ideology. This is often done through in-services, staff meeting, monthly newsletters, and monthly education modules via the organization's intranet.

Leaders help maintain the focus, vision, and mission of the organization while creating a collective culture of individuals who are interdependent and seeking to maximize their talents for the purpose of creating the best possible healthcare outcomes through transparency and disclosure. Healthcare organizations are designed to deal with complexity and do so with great precision, but it requires organizational unity at all levels. Leadership from every facet of the organization, from nursing to medicine, from environmental services to dieticians, and from finance services to administration, must all embrace and be ready to adopt Magnet principles and Just Culture ideology.

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In pursuit of patient safety

The relationship between Magnet recognition and Just Culture is obvious and the benefits of the union are undeniably profound for the healthcare industry. Just Culture unites employees by creating shared responsibility in the pursuit of patient safety, increasing quality of care and awareness, promoting nurse retention through trust, strengthening morale among staff, pursuing excellence as a team, and maximizing the opportunity for organizational learning. Just Culture transforms every mistake and error into an opportunity to learn for the purpose of improving patient outcomes across the entire organization.

Magnet recognition and Just Culture are uniquely aligned to produce a global healthcare shift that's focused on creating a new culture through disclosure, transparency, and public reporting.3 Additionally, pursuing Magnet recognition and Just Culture strengthens professional development, advances nursing and medical science, promotes shared decision making, and unites clinician and nonclinicians for the purpose of patient safety.

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REFERENCES

1. Armstrong KJ, Laschinger H. Structural empowerment, Magnet hospital characteristics, and patient safety culture: making the link. J Nurs Care Qual. 2006;21(2):124–132, quiz 133–134.

2. Reason J. Education and debate. Human error: models and management. BMJ. 2000;320(7237):768–770.

3. Reason J. The Human Contribution: Unsafe Acts, Accidents, and Heroic Recoveries. Burlington, VT: Ashgate Publishing Co.; 2008.

4. Dekker S. Just Culture: Balancing Safety and Accountability. Burlington, VT: Ashgate Publishing Co.; 2007.

5. Mayer CM, Cronin D. Organizational accountability in a just culture. Urol Nurs. 2008;28(6):427–430.

6. Marx D. Patient Safety and the “Just Culture:” A Primer for Health Care Executives. New York, NY: Columbia University; 2001.

7. Leape L, Berwick D, Clancy C, et al. Transforming healthcare: a safety imperative. Qual Saf Health Care. 2009;18(6):424–428.

8. Brous E. The criminalization of unintentional error: implications for TAANA. J Nurs Law. 2008;12(1):5–12.

9. The Joint Commission. Behaviors that undermine a culture of safety. http://www.jointcommission.org/assets/1/18/SEA_40.PDF.

10. Singer SJ, Gaba DM, Geppert JJ, Sinaiko AD, Howard SK, Park KC. The culture of safety: results of an organization-wide survey in 15 California hospitals. Qual Saf Health Care. 2003;12(2):112–118.

11. Hader R. A “just culture” proves just right. Nurs Manage. 2006;37(6):6.

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13. American Nurses Credentialing Center. A new model for ANCC's Magnet recognition program. http://www.nursecredentialing.org/Magnet/NewMagnetModel.aspx.

14. Klienman C. The relationship between managerial leadership behaviors and staff nurse retention. Hosp Top. 2004;82(4):2–49.

15. Wagner C. Is you nursing staff ready for magnet hospital status? An application of the revised Nursing Work Index. J Nurs Adm. 2004;34(10):463–468.

16. Upenieks V. Recruitment and retention strategies: a magnet hospital prevention model. Nurs Econ. 2003;21(1):7–13,23.

17. Aiken LH, Clarke SP, Sloane DM, Lake ET, Cheney T. Effects of hospital care environment on patient mortality and nurse outcomes. J Nurs Adm. 2008;38(5):223–229.

18. Ribelin PJ. Retention reflects leadership style. Nurs Manage. 2003; 34(8):18–19.

19. Day GE, Minichiello V, Madison J. Nursing morale: what does the literature reveal? Aust Health Rev. 2006;30(4):516–524.

20. Sokol PE. Patient safety. Transforming the workplace environment: Port Huron Hospital's transformation model. Nurs Econ. 2004; 22(3):152–153.

21. Ulrich BT, Buerhaus PL, Donelan K, Norman L, Dittus R. Magnet status and registered nurse views of the work environment and nursing as a career. J Nurs Adm. 2007;37(5):212–220.

© 2012 by Lippincott Williams & Wilkins, Inc.

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