Just Culture

I was recently told a story about a nurse.  He had given the wrong patient a drug which was supposed to be given to another patient.  He immediately knew that he had done this and instantly checked the patient, called 111 (this was in the community), informed the family, went with the patient to hospital and stayed with them for the next 16 hours or so.  Also at the same time informed his line manager and even referred himself to the Nursing and Midwifery Council.

If I was this person’s line manager I would clearly want to understand what happened but I would also console the nurse and ask him what I can do for him and applaud him for his actions following the error.  Instead the nurse is being disciplined.  That to me is not applying the Just Culture.

What do we mean by applying the Just Culture?

I recently shared an adapted definition of a just culture from the Skybrary website  at a presentation.  It was:  ‘A just culture is one in which people are not punished for actions omissions/decisions which are commensurate with their experience and training but where wilful and intentional actions are not tolerated’.

Definitions, and trying to bring clarity to a complicated subject, rightly leads to others saying things like ‘well there is a hell of a lot more to it than that!’.

Yes there is.

There are a number of different views on the Just Culture and a fair few myths and misconceptions.

David Marx describes how we should try to distinguish between different behaviours and respond appropriately and proportionately to these behaviours.  His books (Whack a mole and Dave’s Subs) try to help us understand the differences between error, (some refer to is as human error), risky behaviour, reckless behaviour, negligence and criminal intent or wilful acts.  He and others such as Prof James Reason would describe the big three as:

  1. Human error:  inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake
  2. Risky behaviour:  choices that increase risk, where risk is not recognised or is mistakenly believed to be justified – includes violations and negligence
  3. Reckless behaviour:  behavioural choice, intentional acts, conscious disregard to a substantial and unjustifiable risk

There are a number of toolkits, guides, decision trees that try to help with these distinctions. One of them is found at the Skybrary Just Culture Toolkit Just culture section.  Developed by Job Bruggen a safety manager at Air Traffic Control the Netherlands and Patrick Kools of GoGen – Beyond Rules.  A summary of the toolkit is below.

You might want to think of the nurses story at the beginning and ask where the case fits and what the response should have been.

Level – (the behaviour – the response)

  • Level 1 – Exceptionally skilled handling of a safety situation – recognise and reward exceptional behaviour as an important element of a just culture
  • Level 2 – A person suggests an improvement to the system – recognise and reward as a way to motivate others to do the same
  • Level 3 – People helped others to understand and operate the system better – sharing lessons learnt is a major milestone and significant contribution to safety, recognise and reward
  • Level 4 – Day to day good practice – working well on a day to day should not be trivialised, recognise and reward the desirable state to continue to motivate
  • Level 5 – Someone made an error (slips, lapses, omissions, commissions including wrong procedure applied), the actions are unintentional – there are some detailed notes here on what to do in response, I would sum up as understand and find out why, console and support
  • Level 6 – A rule or procedure was not followed – either the rule was not known or the rule was too ambiguous or complicated to understand properly – again there are some detailed notes here and again I would sum up as understand and find out why and coach the person about what they could do differently in the future
  • Level 7 – Although the person knew about the rule and the rule was in principle workable, he or she decided it was not applicable, this could have been to optimise the situation or to be helpful – again there are some detailed notes here and again I would sum up as understand and find out why and coach the person about what they could do differently in the future
  • Level 8 – Person knew the rule and person knew it was not followed but that suited him or her, they were acting recklessly – this needs to be dealt with promptly and may involve sanction although always apply the principle of first understanding and finding out why

Sidney Dekker suggests it is perhaps impossible to draw neat lines around behaviours and that there are blurred boundaries between them; that someone can be both erroneous and risky and what really is the difference between risky and reckless behaviour?  Who gets to draw the line?  He says that an organisation’s journey to a just culture will never be finished.

Justice is one of those categories about which even reasonable people may disagree. What is just to one is unjust to another.

Sidney Dekker suggests having a different mind-set and create a climate of honesty, care, fairness and a willingness to learn, with five key points.  This below is from his excellent editorial in Hindsight.

You might want to think of the nurses story at the beginning and ask whether his treatment is aligned with or misaligned from these points.

Don’t ask who is responsible ask what is responsible.  That people’s actions make sense once we understand the critical features of the world in which they work.  Targeting these features (the what) is an action that contains all the potential for learning, change and improvement.

Link knowledge of the ‘messy details’ with the creation of justice.  What he means here is if someone is going to ‘judge’ another’s actions then they should have all the relevant technical knowledge to do so.  Someone who knows what the work is like, the subtleties of what it takes to get the job done despite the organisation, the rules, the multiple constraints.  So ‘make sure you have the people involved in the aftermath of an incident who know the messy details, and who have credibility in the eyes of other practitioners’.

Explore the potential for ‘restorative justice’. Retributive justice focuses on errors or violations requiring retribution, restorative justice focuses on errors or violations requiring healing.  This acknowledges the multiple truths, each side of the story and point of view about what could have gone wrong and how it normally goes right.  It takes the view that people do not come to work to do a bad job. It fosters dialogue and relationships rather than fostering adversary and create breaks in relationships through sanction and punishment.

Go from backward to forward-looking accountability.  Backward-looking accountability is about blaming people for past events leading to sanction, removal or dismissal of people. This instils a sense of fear and doesn’t help learning, it only leads to reduce reporting and disclosure.  Instead forward-looking accountability sees individual actions as representing organisational, operational, technical, educational and other system issues. People are not a problem to control but a solution to harness.

Put secondary victim support in place.  The practitioners involved in an incident are often referred to as ‘secondary victims’.  This term is not liked by all.  Whatever term we use, Dekker suggests that there should be strong social and organisational support systems for these people.

How about talking about this subject in one of your Sign up to Safety Kitchen Tables?



David Marx.  Books – Whack a Mole and Dave’s Subs

Sidney Dekker.  Book – Just Culture – Balancing Safety and Accountability

Skybrary – website https://www.skybrary.aero/index.php/Toolkit:Safety_and_Justice