The Joint Commission has emphasized the importance of health care organization leaders promoting and ensuring a culture that values reporting of errors without fear of negative consequences to involved individuals.1 In response, health care settings have moved toward adopting a just culture. Just culture recognizes the importance of promoting a nonpunitive and transparent approach to understanding all factors involved with medical errors.2 Within a just culture, employees can admit to their mistakes without fear of punishment. Instead, errors are examined to identify all possible contributing factors, and both individual and system processes are implemented to prevent future errors from occurring.3 While the role of nursing education is to prepare students for the practice setting, nursing academia has not kept up with practice in this regard. This study begins to address that gap by examining student perceptions of just culture in academia.
Background and Review of the Literature
For many years, health care perpetuated a shame and blame culture where those at the point of error were held accountable. However, such a culture does not support or sustain real improvement or protection from future error occurrences.4,5 In contrast, just culture transforms the landscape to allow team members to report errors and identify safety-related concerns, providing a mechanism by which organizations can improve patient outcomes.4-6
The Joint Commission requires a clear system for reporting errors as one component of a comprehensive patient safety program.7 Additionally, the American Nurses Association published a white paper on just culture that challenged not only health care environments, but also nursing education to espouse just culture principles.8 While significant integration of just culture can be found in acute care settings, integration of just culture within nursing education has not been widespread.9 Despite the attempts of nurse educators to align with the health care setting in the preparation of nursing students to enter practice, error reporting systems are not well established in academia. In a recent nationwide survey, only 55% of nursing programs indicated having an error reporting system for student errors during clinical practicum, laboratory, and simulation.10 It is important for nursing students to learn and adopt the values and functions of a just culture during their educational program to be proficient and safe providers in systems that support a just culture.
Academia has traditionally dealt with nursing student errors through various forms of discipline or penalty depending on the severity of the error. These actions perpetuate a culture of shame and blame.11-15 Students believe their errors are held against them and cite this concern as a reason to not make safety reports.11,15,16 A recent survey of nursing students found 57% never or rarely report errors or near misses.17 The literature also reveals that the majority of students do not feel comfortable speaking up about patient safety issues.15-17 RNs report these same barriers to safety reporting and just culture.14-18 Mindful and vigilant monitoring of at-risk behaviors is key to dialog that fosters accountability.19 Students must feel comfortable enough to participate in the monitoring and response system related to human error and at-risk behavior to improve patient safety outcomes.8 Disch et al12 recommend a shared accountability model that promotes collaboration and sharing of responsibilities in nursing education programs. Characteristics of just culture in nursing programs can include accepting that mistakes are part of the learning process, holding students and faculty accountable for creating a safe learning environment, avoiding blame when addressing student error, and disciplining only those who are found to be reckless in their actions.12
Currently, a National Council of State Boards of Nursing–funded research study has created a national data repository for reporting errors and near misses using the Safe Student Reporting (SSR). The SSR tool provides program-specific data and national data on the nature and frequency of student errors and near misses using an anonymous online platform for students and faculty.20 The initiation of a voluntary national tracking system highlights the value of just culture in nursing education and will provide important data about errors, near misses, and systems.
Although just culture has been emphasized as a safety practice, current research indicates students may be entering the workforce inadequately prepared to embrace these initiatives.17 As momentum related to just culture in academic settings grows, a multisite assessment of student perceptions related to just culture in nursing programs using the Just Culture Assessment Tool for Nursing Education (JCAT-NE), a valid and reliable instrument, can provide insight into current perceptions and practices while providing guidance to move the just culture model forward.20
The purpose of this study was to assess prelicensure nursing student perceptions of just culture in academia. The specific aims were to (1) identify student experiences with error reporting systems, (2) determine student perceptions of the elements that support just culture in their nursing programs, and (3) determine differences based on variables that included current level in the nursing program and age.
This multisite study followed a quantitative descriptive design. Twenty nurse educators from the Quality and Safety Education for Nurses Academic Taskforce teaching at 15 different prelicensure nursing education programs from 8 different states served as co–principal investigators (co-PIs) for this study. The participating programs included 13 BSN, 1 accelerated BSN, and 1 associate degree in nursing (ADN) programs.
Institutional review board (IRB) approval was obtained from 1 institution, which served as the IRB of record for the study. Each participating institution followed the policy of their institution to obtain separate IRB approval or entered into an agreement with the primary IRB. Collection of data occurred through a single anonymous online survey distributed to students enrolled in a clinical nursing course.
The JCAT-NE was used to measure students' perceptions of just culture. The JCAT-NE is a 27-item survey instrument that uses a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). The JCAT-NE includes 6 important dimensions of just culture: balance, trust, openness of communication, quality of the event reporting process, feedback, and quality improvement. Development, reliability, and validation of the instrument are described in a previous study.19 Content validation was established using the Content Validity Index; overall scale level universal agreement = 1. Cronbach's α demonstrated reliability of the JCAT-NE as .75 in previous research.19 Reliability of the JCAT-NE in this study was high (α = .936). In addition to the JCAT-NE, basic demographic data about the students and nursing programs were collected.
The sampling frame included prelicensure nursing students enrolled in a course with a clinical practice component at 1 of the 15 identified nursing programs across the United States. The recruitment protocol required each co-PI to secure an internal program liaison to distribute a standardized electronic recruitment invitation to identified eligible students via their institutional email system. A link to access the JCAT-NE via an online survey was embedded within the email invitation. During fall 2018, a total of 1073 participants accessed the online survey and began the JCAT-NE; 849 participants completed all JCAT-NE and demographic questions for a response rate of 79%.
Data analysis was performed using SPSS (IBM, Armonk, New York). After all schools completed the data collection, data were retrieved from the online survey system and reviewed for accuracy and completeness. Surveys with incomplete demographic data or JCAT-NE data that did not meet inclusion criteria requirements were removed. Items that were negatively worded were reverse scored. Descriptive analyses including frequencies and percentages were determined for the categorical sample characteristics, as well as the mean, median, and SD for the continuous variables. Bivariate analyses, using t test, Kruskal-Wallis test, and Mann-Whitney U test, were conducted between the student characteristics and individual survey statements and the JCAT-NE total score. Effect size was manually calculated using the equation r = z/square root of N, where N = total number of cases. Additional bivariate analysis was conducted between each of the survey statements. Statistical significance is α = .05 and α = .017 where Bonferroni correction was applied.
The majority of the students were white (74.2%) and female (88.8%). More than 70% of students reported their nursing program has a safety reporting system. While 15.4% of the students reported being involved in a safety-related event, only 12% had ever reported an event. The majority of participants were in the middle (44.4%) or last (39.3%) semester of their program; only 16.3% were beginning-semester students (Supplemental Digital Content, Table 1, http://links.lww.com/NE/A687).
Overall JCAT-NE Scores
The JCAT-NE total score ranged from 42 to 182 out of a possible 189; the mean was 127.4 (SD, 23.60). Students at the beginning of their nursing program had the highest JCAT-NE total score (mean, 133.6 [SD, 20.52]) followed by the students in the middle of their program (mean, 129.77 [SD, 22.16]). The lowest JCAT-NE total scores were reported by the students at the end of their program (mean, 122.22 [SD, 25.43]). A Kruskal-Wallis test demonstrated a statistically significant difference in JCAT-NE scores between students in different levels of their nursing program, χ2 = 25.09, P < .001. There was strong evidence of a significant difference in scores between students in the last semester and those in the middle or beginning of the nursing program. These results indicate that students at the end of their coursework had significantly lower mean JCAT-NE scores compared with students at the beginning of their coursework.
JCAT-NE by Level of Clinical Coursework
A Mann-Whitney U test was conducted for each survey item comparing students at the beginning to those in the middle and end of their program, and students at the middle to the end of their program (Supplemental Digital Content, Table 2, http://links.lww.com/NE/A688). Across 13 items, students in the beginning and middle of their program rated items significantly higher than did students at the end (Table). For example, data suggest students feel more comfortable discussing safety-related events with nursing faculty/instructors at the beginning and middle of their program than at the end (U = 17 399, z = −4.25, P < .001, r = 0.196; and U = 53 304.5, z = −3.59, P < .001, r = 0.135, respectively). In fact, students at the beginning and middle of their program rated items about positive faculty interactions significantly higher compared to those at the end. These same students indicated stronger disagreement that students are usually blamed when involved in a safety-related event (U = 17 739, z = −4.04, P = < .000, r = 0.186; and U = 52 001, z = −4.11, P < .001, r = 0.154, respectively) and feared less disciplinary action when involved in a safety-related event compared to end-of-program students (U = 17 843, z = −3.93, P = <.001, r = 0.181; and U = 53 271, z = −3.61, P = < .000, r = 0.135, respectively).
The students (n = 849) reported a wide range of ages (19-72 years) with the median age of 22 years (interquartile range [IQR], 21-27 years). The age variable was categorized for further analysis: younger than 24 years (n = 557), 25 to 32 years (n = 169), and older than 32 years (n = 110). A Kruskal-Wallis test demonstrated no significant difference in JCAT-NE score and age, χ2 = 0.597, P = .742. There were 5 items that differed based on age: (1) younger students indicated they trust nursing faculty/instructors to do the right thing, χ2 = 13.901, P = .001; (2) students older than 25 years did not fear disciplinary action when involved in a safety-related event when compared to their younger counterparts χ2 = 35.185, P < .001; (3) Older students reported feeling comfortable reporting a safety-related event in which they were involved, χ2 = 11.867, P = .003; (4) the older students also reported that the safety-related event reporting system is easy to use, χ2 = 8.789, P = .012; and (5) older students were more comfortable with others reporting about safety-related events in which they were involved, χ2 = 9.206, P = .01.
An earlier faculty and administrative survey on safety reporting systems in nursing education programs indicated only 41% have a system for reporting errors and near misses.12 However, 70% of respondents in this study reported their program has a safety event reporting system, indicating that students and faculty have contrasting perceptions. Although this study did not measure what percentage of respondents had committed an error, only 12% of those stating their program has a safety event reporting system described ever submitting a report. This number, although low, is consistent with the literature about student reluctance to report errors.16 Student responses indicated low scores for ease of safety reporting system use, being given time to make reports in clinical practice after an error, and faculty encouragement of safety reporting. This may account for the low number of students indicating they had reported an error event. Results suggest that students lack awareness about safety-related events within their program as indicated by low scores for “We do not know about safety-related events that happen within our nursing program” and “I often hear about safety-related event conclusions and outcomes.” Student lack of awareness about safety-related events is consistent with conclusions from previous research.17
This study is the first multisite study to describe nursing student perceptions of just culture using a valid and reliable instrument. Although overall JCAT-NE scores clearly indicate students do not perceive just culture exists in their nursing education programs, individual items demonstrate students do not feel blame when errors occur. This result is different from previous literature.11-15 More consistent with the literature is the perception of students at the end of their programs that error reporting is used to “tattle” on others and that peers discourage each other from using the safety event reporting system.11,15
Most concerning is the finding that as students progressed through their nursing program, positive perceptions of just culture declined, as evidenced by the overall mean scores between students at the beginning and those at the end of the nursing program. While this may seem counter to desired outcomes of nurse educators, it may accurately describe the evolving perceptions and experiences of nursing students as they mature in the nursing role. One explanation may be that as students progress through their nursing curriculum, they spend more time in the clinical setting where they are increasingly influenced by the clinical site culture. This finding aligns with the literature that describes students' decreased willingness to question and report safety concerns as they progressed through the nursing program.15-21 Future research should evaluate whether students' evolution of knowledge and experiences impact their perceptions and subsequent actions related to just culture.
Implications for Nurse Educators
The results from this study are a call to action for nursing education programs and individual nurse educators to emphasize the characteristics of just culture, error reporting, and quality improvement. Nursing programs should identify areas for improvement to systematically increase the presence and perception of just culture structure and processes. They should provide deliberate and consistent safety-specific messaging, which follows a quality improvement framework, to engage students in just culture at the program level. Program-level education and policy review may be required to introduce new methods of managing at-risk behaviors. Additionally, effectively monitoring and measuring student perceptions of just culture are an important step to establishing and improving just culture in schools of nursing. Individual faculty should encourage and discuss error reporting in an intentional and a consistent manner in all coursework. Deliberate actions such as intentional conversation, modeling, prompting of peer discussions, and allowing time for error reporting during clinical practice can make an impact in improving just culture perceptions.
A limitation of the study is convenience sampling, which limits generalizability. In addition, this study used only quantitative measures rather than a mixed-methods approach. Further exploration using qualitative methods could have formed a more comprehensive approach to learning about just culture perceptions among students.
The findings of this study provide a stepping-off point for discussion among faculty and administrators to identify and implement structures and processes that will support student development and values related to the concepts of just culture. Future investigations into why students' perception of just culture changes as students progress through the program may offer valuable insights into actions that can be taken by faculty and administrators to build a sustainable just culture that supports error reporting as a mechanism for patient safety.
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