Halloween is over. The scary ghouls and goblins that decorated lawns are now packed away in Rubbermaid containers and stowed safely in the basement or garage for another year. But there is one thing associated with the yearly fright fest that doesn’t get stored up in the rafters with everything else — fear.
Fear is present 365 days a year. If you listen to the news, we’re afraid of fiscal cliffs, government shut-downs, NSA phone tapping, genetically modified food, the fate of Detroit and the Kardashians (as well we should be). In a few weeks, as predictably as Black Friday sales roll around, fear over this year’s flu strain will start to take over.
I wish fear could be blamed on the media or that I could say the perception of fear is just that, a perception not a reality, but unfortunately I can’t. I’ve seen the presence of a great deal of fear in the healthcare industry.
In healthcare we’re afraid of healthcare reform, insurance companies, accrediting bodies, contaminated medications, computers, making a mistake, getting accused of malpractice and getting sued.
It seems fear is stronger now than when I went to nursing school 15 years ago. Then we were reminded of the importance of charting with the phrase, “If it wasn’t charted, it wasn’t done.” Now it’s, “Be sure to ‘cover your a$$’ when you chart,” and “Make sure you include this in case we get audited.” Charting isn’t about making sure the staff following you have clear, up-to-date information about patients. It’s now about assuming your interactions will be called into question, quite possibly in a court of law.
I recently heard a friend use the term “fear-based nursing practice” to describe the CYA mentality. When providers practice healthcare out of fear, they are reacting to all the “what-ifs” that could happen rather than responding to the patient’s needs. They start to lose confidence in their skills and the care they provide. The provider-patient interaction loses its warmth and genuine nature and a wall goes up to protect yourself from this person who might sue you.
Defensive medicine is another way of describing the way fear has taken hold in our healthcare system. According to a study published in Health Affairs in August, physicians who said they had a high level of malpractice concern also practiced medicine defensively by ordering more tests or sending patients to the ER. The study concluded:
“Reducing defensive medicine may require approaches focused on physicians’ perceptions of legal risk and the underlying factors driving those perceptions.”
I think the thing healthcare providers fear most, be they nurses, physicians, physical therapists, pharmacists, is making a mistake. We all got into the healthcare field to help, not harm someone. Yes, mistakes in our line of work can be deadly. But they can also be teaching moments that bring fixable flaws in our delivery systems to light.
This is the idea behind the Just Culture concept. Just Culture was created in the 1990s by David Marx, a Boeing design engineer who began a research and consulting practice focused on managing human error through the integration of systems engineering, human factors and the law.
Just Culture is a system used to “implement organizational improvement, presenting a set of design laws that influence our ability to create the societal outcomes we desire.” Basically, if a mistake occurs, a manager in a Just Culture would look at the systems to see how they contributed to the error and take into account the staff member’s behavior before determining consequences.
“In ‘hospital A,’ a nurse, not wanting to disturb a sleeping patient, does not check a patient’s name band and administers an IV antibiotic to the wrong patient, who was allergic to that drug. The patient has an anaphylactic reaction and ends up in the ICU on a respirator. How do we judge this nurse’s behavioral choice not to check the name band before administering the medication? Do we punish her? Some organizations would punish the nurse (i.e., retrain, reprimand, or dismiss) because she violated the patient identification policy.
“A just culture would want to know:
- Was the nurse aware of the policy to check name bands?
- Was it possible to check the name band?
- Do all the nurses on the unit check name bands prior to administering medications?
- Why didn’t the nurse check the name band? Did she mistakenly believe it was better not to? Why?
“The error in this scenario is administering the medication to the wrong patient. We determined the nurse’s behavior to be ‘at-risk’ (and not ‘reckless’) because the nurse violated the policy for what she believed to be a good reason—allowing the patient to sleep. It turns out that customer satisfaction scores had recently been reviewed at a staff meeting, and sleep interruption was identified as the number one concern of patients. In addition, the other nurses on the unit agreed that they have not awakened patients to check name bands many times.”
Five skills — values and expectations, system design, behavioral choices, learning systems, accountability and justice — and three behaviors —human error, at-risk behavior, reckless behavior are the pillars a Just Culture is built on. The Just Culture algorithm acts as a guide to help evaluate events.
I think the Just Culture concept is an antidote to the fear that has wound its way into healthcare practice. In most settings, it’s difficult to say, “I didn’t know that,” “I need help,” or “I made a mistake.”
If a nurse was to utter any of those phrases he or she would jeopardize what every nurse out there wants to be labeled: A Good Nurse. If I admit I’m weak, people won’t think I’m a good nurse. If I make a mistake, then I’ll be: A Bad Nurse, and probably lose my job.
But in a Just Culture there is hope that glitches and mistakes can be turned into learning opportunities. A system may need to be revised because it contributed to an error. Or the nurses may need more education on a new piece of medical equipment. It takes the emotion and judging out of unexpected events and substitutes logic and compassion to help staff grow.
What are your thoughts on a Just Culture environment? Do you work in a Just Culture?
Jennifer Thew, RN, MSJ
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