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September 24th, 2021

Just Culture Agreement

A just culture helps create an environment where individuals feel free to report mistakes and help the organization learn from its mistakes. This contrasts with a “culture of guilt”[3] in which individuals are fired, punished or otherwise punished, but the causes of the error are not examined and corrected. In a culture of guilt, mistakes cannot be reported, but rather hidden, which ultimately reduces organizational results. Organizations often determine the response to an error based on its severity.10 Errors that do not cause harm are minimized or ignored, and those that cause injury or death are highly punitive. All types of mistakes have the same meaning in a just culture, not just those that have poor outcomes. In order to build trust, the identification and reporting of errors is encouraged in order to provide opportunities for training and reorganization of the system. When an organization moves into a learning environment by disclosing events, it fosters confidence in improvement, not distrust of accusations. This is considered essential to becoming an extremely reliable organization.11 While the healthcare sector is quite new, culture is not a new approach. Industries such as aviation use non-incriminating error detection systems to improve safety and reliability.

In the 1970s, the aviation industry`s attention shifted from determining who made a mistake to identifying the circumstances in which an error was made3 By understanding the circumstances of the error, changes can be introduced to prevent similar errors from occurring. Air travel is now the safest means of transport. During boarding and annually, nurses are notified of the notification of actual security incidents when they are identified. Potential events do not have the same mandatory reporting expectations, but offer the same learning opportunities. They are just as valuable in the search for reliability. The correlation indicates that if nurse clinicians trust their superiors, they are more likely to talk about potential errors or near-errors. Another investigative element in the area of JCAT error reporting, “Employees discourage each other from reporting events,” was unfavorably linked to trust, which also indicates that nurses are more likely to encourage each other to report events when trust increases. If there is a non-punitive reporting process, the organization can become highly reliable and learn from a careful analysis of all events.9 The results of the study showed a statistically significant difference between the perception of trust and equitable culture within the organization by executives and nurse clinicians. These results are worrying because the organization sees itself as a just culture. If culture is right for an organization, it is expected that fair treatment will create a sense of trust in staff.

Perceptions of unfair treatment and accusations suggest a possible reluctance on the part of nurse clinicians to report events or even worse to hide. Open communication is the basis of a reliable organization, where security events serve as a learning opportunity instead of holding a person to account. The results of the study provide practical suggestions for organizations to develop a culture of trust and fairness. This can lead to an environment where incidents are analyzed on the basis of the system where clinical nurses operate.13 Incidents do not occur in professional silos. Therefore, studies should also not be independent of one another. .

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