Just Culture

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Influencing Leadership Perceptions of Patient Safety Through Just Culture Training

Amy Vogelsmeier, PhD, RN, BC-GCNS; Jill Scott-Cawiezell, PhD, RN, FAAN; Becky Miller, MHA, CPHQ, FACHE; Scott Griffith, MS

There are differences in perceptions of safety culture between healthcare leaders and staff. Evi-

dence suggests that an organization’s actual safety performance is more closely reflected in staff

perceptions suggesting that frontline staff may be more aware than the leadership of actual patient

safety challenges within their organization. Closing the perception gap between healthcare lead-

ers and staff is critical to aligning the resources and strategies required to create a true culture of

safety. Key words: healthcare leadership, just culture, patient safety

MORE THAN 10 YEARS have passed sincethe Institute of Medicine’s report, To Err Is Human, called attention to the na- tion’s unacceptably high rate of deaths and ad-

verse events related to medical error.1 Regu-

lators, researchers, and healthcare providers

continue to bring attention and resources to

the challenges of medical error, yet adverse

events related to medical error continue to be

on the rise.2 While the refractory nature of

medical error prevention has been considered

through different lens,3,4 most would agree

that an organization’s culture toward safety is

critical to support an environment in which

prevention of medical error can occur.

Author Affiliations: Sinclair School of Nursing, University of Missouri, Columbia (Dr Vogelsmeier); University of Iowa College of Nursing, Iowa City (Dr Scott-Cawiezell); Missouri Center for Patient Safety, Jefferson City (Ms Miller); and Outcome Engineering LLC, Plano, Texas (Mr Griffith).

This research was funded by the National Council State Boards of Nursing grant P27001.

Corresponding Author: Amy Vogelsmeier, PhD, RN, BC-GCNS, S314, Sinclair School of Nursing, University of Missouri, Columbia, MO 65211 (vogelsmeiera@ missouri.edu).

Accepted for publication: February 9, 2010

With evidence suggesting that organiza-

tional culture has an impact on patient safety

practices,5 several studies have considered

the implications of both a culture of safety

and a culture of blame.6-8 Through this ex-

ploration of cultural impact on patient safety

practices, experts have discussed the leader’s

influence on the organization’s ability to un-

cover medical error and related opportuni-

ties to improve.1,9 A concern, however, is

while many healthcare leaders declare patient

safety as an organizational priority and are

convinced they see evidence of safety,10 front-

line staff continue to report concerns about

actual safety practices and priorities.8,10-12

Perhaps the divergence in patient safety

perceptions between leaders and staff is

rooted in a culture of blame. Early patient

safety discussions focused consistently on

medical error as being linked to individu-

als (blame).13,14 This long-standing focus on

blame has inadvertently dampened the will-

ingness of frontline staff to bring forth med-

ical error, near misses, and opportunities for

improvement.10,11 As such, because safety is-

sues are not brought forth by those at the in-

terface of care, leaders may have a false sense

that their organizations are actively managing

patient safety issues.

288

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Influencing Leadership Perceptions of Patient Safety 289

A new approach to medical error manage-

ment has evolved over the past decade with

many efforts pointed toward uncovering orga-

nizational systems that set up staff for unsafe

practices.5,9 However, despite efforts to focus

on systems, many staff continue to be fear-

ful of blame when medical errors occur.8,10,11

Thus, the question remains, where are we in

terms of creating a culture of safety in health-

care organizations across the country? If front-

line staff members continue to perceive in-

dividual blame, then we have not achieved a

shared commitment and approach to patient

safety.

A shared commitment and approach to

patient safety can occur in a just culture.

Just culture emphasizes shared accountabil-

ity between leaders and staff to support error

disclosure and organizational learning from

mistakes.5 In a just culture, leaders are ac-

countable to create an environment support-

ive of error disclosure and to manage organi-

zational issues brought forward by staff that

impede safe care. In turn, staff members are

accountable to share information and expe-

riences encountered with errors and error-

prone systems. Because staff and leaders share

information, leaders better understand the or-

ganizational realities experienced by staff and

staff better understand the leaders’ efforts to-

ward improvement. Perhaps this shared un-

derstanding created through a just culture can

close the perception gap between leaders and

staff. The purpose of this article is to describe

the influence of Just Culture training on lead-

ers’ perceptions of their patient safety culture

and to explore how those perceptions align

with staff across the nation.

JUST CULTURE COLLABORATIVE

With the desire to improve the culture of

safety in Missouri, the Missouri Center for Pa-

tient Safety engaged 63 healthcare provider

organizations of varied size and setting to par-

ticipate in a statewide collaborative called the

Missouri Just Culture Collaborative. In addi-

tion, 4 statewide regulatory agencies includ-

ing the State Board of Nursing, professional

Table 1. Overview of just culture training

Champion and healthcare leader training

The management of risk

Role of systems design

Management of human error

Management of at-risk behavior

Management of reckless behavior

Role of event investigation

Just culture algorithm

Duty to produce an outcome

Duty to follow a procedural rule

Duty to avoid causing unjustifiable risk or

harm

Case scenarios with applied decision-making

algorithms

Audio conferences (select topics)

Just culture implementation

Event investigations

Managing human resources

Managerial accountabilities

On-site training

Executive medical staff briefing

Training for healthcare managers and

supervisors

Safe choices for staff

Reprinted with permission from Just Culture Training for

Healthcare Managers, Outcome Engineering, LLC. Copy-

right 2008.

schools, and state nursing associations partic-

ipated. Of the 63 healthcare organizations, 52

completed the 20-month collaborative. The

collaborative, funded by the National Council

State Boards of Nursing and approved by a lo-

cal institutional review board, was formed to

assist leaders from healthcare organizations in

identifying and managing organizational sys-

tems and human issues that lead to medical

error. The collaborative partnered with Out-

come Engineering LLC to provide Just Cul-

ture training to leadership staff from health-

care systems, acute care and critical access

hospitals, physician practices, and nursing

homes.15

As noted in Table 1, Just Culture train-

ing emphasizes a system of shared ac-

countability among organizational leaders

and staff. Through the education, healthcare

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290 JOURNAL OF NURSING CARE QUALITY/OCTOBER–DECEMBER 2010

organizations considered healthcare leaders’

accountability for designing safe systems and

responding to staff in a fair and just manner.

In addition, participants considered how staff

members are also accountable for making safe

choices and reporting errors and bringing for-

ward opportunities for improvement.16

The 52 participating healthcare organiza-

tions engaged in the Just Culture Collaborative

in 1 of 4 ways (ie, 4 levels of intensity). Four

healthcare organizations chose to minimally

engage and simply sent 1 organizational cham-

pion to the initial Just Culture training. Sixteen

healthcare organizations chose to take 1 more

step and attended a second training session,

which included educating a group of their or-

ganizational leaders such as executive staff,

medical directors, and management staff. Fif-

teen healthcare organizations chose to en-

gage at a third level that included monthly au-

dio conferences in addition to the previously

mentioned Just Culture training for a group of

their organizational leaders. Finally, 17 health-

care organizations fully engaged by partici-

pating in all opportunities noted above and

additionally participating in an on-site Just

Culture training session, which included train-

ing for frontline staff. Thus, the higher the

level of engagement, the more members of

the organization were involved and exposed

to discussions related to just culture.

EXPLORING LEADER PERCEPTIONS OF THEIR PATIENT SAFETY CULTURE

To explore how leaders’ perceptions of

their patient safety culture might be influ-

enced by Just Culture training during the

collaborative, leaders from participating or-

ganizations enlisted a wider variety of their

leadership team to participate in an adapta-

tion of the Agency for Healthcare Research

and Quality’s Hospital Survey on Patient Safety

Culture (HSOPSC) before and after the col-

laborative. The HSOPSC, a valid and reliable

survey, is designed to assess hospital staff

perceptions of a patient safety culture mea-

sured across 12 dimensions of safety.17 The

HSOPSC, modified for this collaborative to in-

clude 3 open-ended questions specific to er-

ror reporting, leadership response, and feed-

back to error, was used to measure change in

leadership perceptions of their organization’s

patient safety culture as influenced by the Just

Culture training intervention.

A variety of leadership staff, predominantly

nurse executives, nurse managers, and nurs-

ing supervisors from the 52 healthcare organi-

zations completed the Agency for Healthcare

Research and Quality safety culture survey;

485 leadership staff completed the survey be-

fore the collaborative and 439 leadership staff

completed the survey after the collaborative.

The project team, led by a nurse researcher

(Scott-Cawiezell), selected 14 items from 8 of

the 12 survey dimensions that the team con-

sidered most influenced by content included

in the Just Culture training. The 8 dimensions

included communication openness, feedback

and communication about error, frequency of

error reported, manager expectations/actions

promoting patient safety, management sup-

port for patient safety, nonpunitive response

to error, organizational learning, and overall

perceptions of safety.

Exploring select survey items from these

8 dimensions, the project team initially at-

tempted to compare changes in participants’

perceptions as noted before and after the

collaborative. However, it quickly became

evident that focusing on “change scores”

was providing neither meaningful informa-

tion nor reasonable explanations for the ac-

tual changes in perceptions noted throughout

the collaborative. As the survey results were

considered, it was immediately evident that

the most fully engaged organizations were

not showing the same pattern of perceptual

change as the least engaged organizations. For

example, when considering questions related

to an organization’s nonpunitive response to

error, the most engaged healthcare organiza-

tions showed a positive change of only 1.1%

while the lesser engaged healthcare organi-

zations showed a positive change of more

than 17%, moving toward strongly agree-

ing that nonpunitive approaches were the

standard approach of the organization. The

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Influencing Leadership Perceptions of Patient Safety 291

pattern continued as the team explored the

remaining select items of the safety culture

survey.

With these intriguing findings, the project

team then aligned leadership staff scores from

the least engaged organizations and the most

engaged organizations with the 2009 HSOPSC

national findings.18 The 2009 results reflect

the perceptions of nearly 150 000 hospital

management and staff including 13 750 lead-

ers and 66 261 nurses and serve as a na-

tional database for healthcare organizations.

Based on the evidence suggesting that front-

line staff perceptions of patient safety re-

flect more accurately an organization’s safety

performance,5 the HSOPSC database pro-

vided an important comparison between col-

laborative leadership participants and front-

line staff, particularly nurses from across the

country.

As noted in Table 2, benchmarking against

the national scores revealed that leaders’ per-

ceptions from the most fully engaged organi-

zations approximated more closely with the

perceptions of nurses across the country for

the selected items than those of the least

engaged organizations. For example, when

considering communication openness, the

statement, “Staff feel free to question the de-

cisions or actions of those with more author-

ity,” 57% of leaders from the most engaged or-

ganizations either agreed or strongly agreed

that their staff perceived this freedom. This

response more closely approximated to the

national benchmark of nurses, at which only

45% agree or strongly agree that they had this

freedom. This is in contrast to perceptions

of the least engaged leaders who all believed

their staff would feel free to question deci-

sions or actions.

Another statement, “Staff (do not) feel like

their mistakes are held against them,” ex-

plored leadership perception of punitive re-

porting within their organizations. Only 59%

of leaders from the most engaged organiza-

tions agreed with this statement and more

closely aligned with 50% of nurses across the

country who also agreed with it. This is again

in contrast to the least engaged leaders of

whom 75% believe their staff do not feel their

mistakes are held against them. This pattern

of comparison between the most and least

engaged organizations was consistent across

each of the 8 survey dimensions.

Furthermore, when we explored responses

from the open-ended questions, the differ-

ence in perceptions between the most and

least engaged organizations was further vali-

dated. Leaders from the most engaged health-

care organizations more often recognized or-

ganizational barriers to open communication

and staff hesitancy to report errors; many

also believed “pockets of employees” still fear

blame. This was in contrast to participants

who were least engaged who rarely cited er-

ror reporting barriers nor believed their staff

feared blame.

CLOSING THE GAP BETWEEN LEADERSHIP AND STAFF

At first glance, findings from this collabora-

tive seem counterintuitive because organiza-

tions most engaged in the Just Culture training

showed the least amount of positive change in

their perceptions of a safety culture, whereas,

those least engaged had the greatest amount

of positive change. Moreover, leaders from

the most engaged organizations reflected a

less positive perception of their patient safety

culture than the least engaged organizations

whose leaders’ perceptions were consistently

positive. This pattern held true across each of

the 8 selected dimensions of safety.

Initially, one might jump to the conclusion

that this negatively reflects on the organiza-

tions most exposed to discussion and educa-

tion about leadership and staff accountability

in patient safety. However, when benchmark-

ing against national findings where percep-

tions of nurses and other frontline healthcare

providers are considered, those organizations

most fully engaged were most aligned with

the perceptions of staff, specifically nurses

from across the nation. Furthermore, the

written responses of the fully engaged health-

care organizations provide clear and consis-

tent acknowledgment of barriers to error

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Table 2. Comparison of most engaged and least engaged healthcare organizations benchmarked with selected national responses

Select items for comparison National National (scores reflect % of positive responses responses responses of strongly Least Most leaders only nurses only agree/agree) engaged engaged (13 750)18 (66 261)18

Communication openness

Staff will freely speak up if they see

something that may negatively affect

patient care

100 77 83 75

Staff feel free to question the decision or

actions of those with more authority

100 57 68 45

Feedback and communication about error

We are given feedback about changes put

into place based on event reports

75 61 64 51

In this unit, we discuss ways to prevent

errors from happening again

100 83 82 66

Frequency of events reported

When a mistake is made but is caught

and corrected before affecting the

patient, how often is it reported?

75 41 58 48

When a mistake is made that could harm

the patient, but does not, how often is

this reported?

100 61 78 76

Manager expectations/actions promoting

patient safety

My manager (does not) overlook

patient safety problems that happen

over and over

100 84 85 76

Management support for patient safety

Management provides a work climate

that promotes patient safety

100 90 89 73

Management (does not) seem interested

in patient safety only after an adverse

event

75 68 75 55

Nonpunitive response to error

Staff (do not) feel like their mistakes are

held against them

75 59 69 50

Organizational learning-continuous

improvement

Mistakes have led to positive changes

here

100 82 80 60

Overall perceptions of safety

It is (not) just by chance that more

serious mistakes do not happen here

75 66 72 59

Our procedures and systems are good at

preventing error from happening

100 70 77 66

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Influencing Leadership Perceptions of Patient Safety 293

reporting and frightened and hesitant front-

line staff. Recognition of underreporting and

fear suggests that fully engaged healthcare or-

ganizations may have developed a clearer un-

derstanding of the realities experienced by

their nurses and other healthcare providers.

In contrast, less engaged healthcare organi-

zations continued to hold on to the illusion

that “we have no real problems here.” The

perception that “no real problems” exist ap-

pears to align with the perceptual gap ex-

plicated between leaders and staff in earlier

studies.8,10,12

Because training for the most fully engaged

healthcare organizations included both lead-

ership and staff coming together, the shared

dialogue and education provided a platform

for shared experiences to be discussed and

explored. Furthermore, because just culture

principles emphasize shared accountabilities

among leaders and staff for managing error

and risk for error, Just Culture training may

have facilitated staff willingness to share ex-

periences that lead to error and error risk

within their organizations. The open discus-

sion, thus, may have enlightened leaders to

the true challenges that staff members en-

counter in ensuring patient safety. In contrast,

because the least engaged healthcare organi-

zations did not fully benefit from Just Culture

training, specifically on-site training, leaders

and staff did not have the opportunity to share

in these critical discussions and critical in-

sights. As such, a divergence in patient safety

perceptions between leaders and staff may

remain.

Several studies have attempted to shed light

on the differences between organizational

leaders’ and staff’s perceptions of patient

safety.6,10,12,19 Singer and colleagues10 pro-

vide more evidence to clarify the differences

in leaders’ and staff’s perceptions. These au-

thors found that an organization’s actual safety

performance was more closely reflected in

staff’s perceptions of safety, suggesting that

staff more closely align with the realities of

organizational patient safety challenges. Thus,

the ongoing challenge remains, how do we

close the perceptual gap to more closely align

leaders with staff so substantive changes can

result in sustainable improvement?

CONCLUSION

While findings from this collaborative are

important for recognizing how leadership

staff perceptions may have been influenced

by Just Culture training, there are limitations.

First, the survey was limited to leaders’ per-

ceptions and did not include internal staff

comparisons. While the results were com-

pared with a national database, it is possi-

ble that staff within these organizations may

have responded differently. Second, organiza-

tions engaged voluntarily in varying levels of

the project so those organizations most en-

gaged made a commitment to do so. As such,

the most fully engaged organizations were

likely more open to leadership and staff inter-

actions before the collaborative. Finally, the

small number of least engaged organizations

poses some limitations to the findings. How-

ever, despite the small numbers, the consis-

tency of positive responses clearly indicates a

pattern of agreement among the least engaged

leaders.

Despite the limitations, findings from this

collaborative provide important insight into

the opportunity to close the gap in percep-

tion between leadership and staff. Closing the

perceptual gap can lead to a shared priority

for patient safety. Because just culture empha-

sizes a shared accountability between leaders

and staff to make patient safety a priority,16

perhaps the shared training between lead-

ers and staff emphasized those accountabil-

ities and opened up a new series of discus-

sions. Minimizing a culture of blame, in which

leaders accept accountability for safe systems,

and creating an environment in which staff

feel free to openly report errors and systems

vulnerabilities must start with leadership ac-

knowledgment that barriers exist. Once lead-

ers and staff have a shared understanding

of the organizational challenges to providing

safe care, perhaps a true safety culture can

exist.

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294 JOURNAL OF NURSING CARE QUALITY/OCTOBER–DECEMBER 2010

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