NURS 8302 Discussion Just Culture

ByAtlas Essays

Initial Post-Week One Discussion Two

Explanation of whether my organization uses a just culture: Errors rarely occur in a vacuum; instead, they result from several events with several opportunities for correction. A just culture provides a haven for reporting. In other words, Just Culture promotes fairness and accountability when addressing errors or incidents in healthcare settings. Organizations, not individuals, are held accountable in a fair culture setting for the procedures they build and the occurrence analysis (Paradiso & Sweeney et al., 2019). My organization uses a just culture when an error is committed. Rather than solely blaming individuals, the organization recognizes that errors can occur due to system failures, human factors, or a combination of both. My organization uses peers to review errors committed by fellow peers and make recommendations. For example, one of my colleagues had a patient with a medical emergency; she ordered all the necessary tests but did not evaluate the patient physically, and the patient died. She was the only nurse practitioner working that night. When peer-reviewed, she was told she provided suboptimal care and would have to examine her patients in the future. There were no additional punitive measures, but her department made sure to schedule two nurse practitioners to avoid situations like this in the future.

How does just culture impact quality and safety for my healthcare organization, and why: Because a just culture stress learning from mistakes, strengthening processes, and establishing an environment where healthcare personnel feel comfortable disclosing errors and near-misses without fear of punishment, implementing a just culture can lead to increased quality and safety for the company. Furthermore, establishing a just culture aims to balance holding individuals accountable for their actions and comprehending the underlying circumstances contributing to errors, promoting open communication, a safe culture, and better patient care (Boysen, 2013).

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DNP-prepared Nurse’s role in supporting a just culture in an organization: As a DNP-prepared nurse, I can play a critical role in supporting a just culture in my organization by promoting open communication. This can be done by encouraging a culture of transparency and open dialogues where healthcare professionals feel comfortable reporting errors or near misses and emphasizing the importance of learning from mistakes and improving systems. Additionally, I can advocate for developing and implementing fair policies that balance accountability with understanding the complexities of healthcare delivery, promoting policies that focus on system improvements rather than solely blaming individuals, and, lastly, serving as a role model by demonstrating a commitment to a just culture by modeling open communication, accountability, and willingness to learn from mistakes and encourage others to do the same (Baarle et al., 2022).

By embracing my DNP-prepared role, I can create a culture of fairness, learning, and continuous improvement within my organization, ultimately enhancing patient safety and the overall quality of care.

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NURS 8302 Discussion Just Culture

NURS 8302 Discussion Just Culture

Just culture refers to an organization sharing the accountability for the system they have designed and how this can affect the behavior of their employees.   My current organization does not use a system of just culture when it comes to their nursing staff.   Our focus has become appeasing the patients and making sure they are happy with the services and care.   Unfortunately in certain populations the demands are never ending, and it is impossible to appease them and provide safe and quality care to them, as well as to your other patients.   The organization can be very punitive and nurses are written up for any little mishap.  This creates fear in the nurses and often causes them to focus on the wrong things;  For example:   A RN might be so focused on things getting the patient certain foods, set up in the bed right so they are completely satisfied that they might neglect another patient who has more urgent needs like getting transfused blood products or timed lab work.   Unfortunately as a NP covering the floors I come across this issue all the time.   An RN will call me for  sleep aide for a patient at 8pm and neglect to tell me their blood pressure dropped to the 80’s or that the post transfusion CBC that was due 4 hours ago has never been completed.  This punitive culture has had a great impact on the culture of safety at this institution.  Improving the culture of safety within health care is an essential component of preventing or reducing errors and improving overall health care quality PSET. ( 2019).  This system is not effective because often it causes the staff to focus on the wrong things and it also causes the staff to doubt the intuition and nursing judgment because they are so focused  on appeasing the patient.

I am a true believer that education can fix almost all problems we come across.   As a DNP prepared nurse in a institution that does not practice just culture; we can be that catalyst of change.  we can bring up these issues with upper management, along with studies and data that support Just Culture’s role in supporting patient safety and quality care.   When an institution can see how Just Culture is working in a similar setting, they might be more open to adapt it into their organizations.  As a DNP i would also collect  data during my practice ( leaving out names of nurses and patients of course ) to show the organization leaders how their punitive culture affects the practice of the RN and therefore inhibits patient safety, and often causes delay of treatment.   Again, showing the institution how their present method an actually cause a decline in patient safety and and quality care will play a vital role in getting them to adapt Just culture into their organizations also.

In a organization that already uses Just Culture; the DNP role would be to continue to support this system by participating in reviews of errors.    Supporting a environment of Just culture is multi factorial and has to include all involved from the head of the organizations and all the way down to those at the bedside.   Being an active member of these committees to see how the error occurred, where the mishap happened and how can we prevent a similar error from happening.   The DNP can also support Just Culture by speaking with the staff members involved with the error,  assessing where they went wrong and educating them as to how they could have handled them.

References:

PSNet. (2019(.  Culture of Safety Agency for Healthcare research and Quality

https://psnet.ahrq.gov/primer/culture-safety

NURS 8302 Discussion Just Culture

As an alternative to a punitive system, application of the Just Culture model, which has been widely used in the aviation industry, seeks to create an environment that encourages individuals to report mistakes so that the precursors to errors can be better understood in order to fix the system issues.

—American Nurses Association, 2010

Mistakes happen. There is no way to avoid all mistakes, so how might your practice change if the reporting of mistakes was welcomed, versus penalized? How might this lead to a better understanding of quality improvement and safety needs? How might patient safety be improved?

For this Discussion, consider the role of just culture in your organization. Reflect on your experience with just culture and consider how this model might support patient care.

Reference:
American Nurses Association. (2010). Just culture [Position statement]. https://www.nursingworld.org/~4afe07/globalassets/practiceandpolicy/health-and-safety/just_culture.pdf

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To Prepare:

  • Review the Learning Resources for this week, and reflect on your experiences with just culture.

    nurs 8302 discussion just culture
    NURS 8302 Discussion Just Culture
  • Consider how just culture connects to quality and safety. What is the role of the DNP-prepared nurse in promoting just culture in organizations and nursing practice?

By Day 4 of Week 1

Post an explanation of whether your organization uses a just culture. Then, explain how this might impact quality and safety for your healthcare organization, and why. What is the DNP-prepared nurse’s role in supporting a just culture environment in a healthcare organization? Be specific and provide examples.

Just Culture

Accidents involving injuries or fatalities are frequently caused by human error. According to Quillivan (2020), those involved in accidents or errors are frequently held accountable and may face punishment to resolve the issue. Although the error is the system’s fault, it is frequently assumed that the individual is to blame. The issue would persist if the system remained unchanged and people were altered instead. According to Battard (2017), medical errors result from flawed systems, circumstances, and procedures rather than the fault of healthcare professionals. The culture of safety can be achieved in a good working environment. However, due to the persistence of harsh work situations, frontline employees in most healthcare businesses are at risk of medical errors.

Establishing a Just Culture in my organization

Healthcare organizations must be open and honest about reporting medical errors for patient safety. Transparency entails having no secrets to allow medical errors to be discussed publicly and information to flow freely (Quillivan, 2020). Furthermore, openness promotes accountability and fosters confidence when freely sharing medical errors. Therefore, a just culture is required for Transparency to occur—an atmosphere of candor and openness results from a just culture. In my organization, healthcare workers are encourage to report medical errors. For example, when a nurse commit a medical error in my organization, the case is investigated, and the nurse is send for further training. There was a case where a nurse in my unit did not follow up with the pharmacy to obtain insulin for a diabetic patient. The patient was later sent to ICU for  DKA. The nurse was sent for training and got a warning from the hospital administration. Nurses are also reported to the board of nursing, suspended or terminated for medical errors that result to fatal injury or death. While the healthcare institution owes its patients and staff a duty, everyone is ultimately accountable for their choices. Healthcare professionals should not be held accountable for systemic errors they cannot control. However, a just culture is a shared obligation that should address all medical issues in a facility (Battard, 2017). Therefore, when nurses respect safety and exercise caution when there is a threat to safety, a just culture is established.

The Role Nurse Leaders

Ensuring public safety through developing a just culture requires a shared duty between businesses and employees. Shared responsibility creates a setting where mistakes and faults can be carefully examined to promote learning (Nash, D. B., Joshi, M. S., Ransom, E. R., & Ransom, S. B. (Eds.). 2019). Establishing a culture of accountability and responsibility for patient safety is a duty and responsibility of nurse leaders. As mistakes are revealed, nurses must be held accountable and responsible to move toward a just culture. Accountability and responsibility entail determining why mistakes occur and which conditions, systems, and procedures are to blame (Quillivan, 2020). In order to prevent medical errors, nurse leaders must supervise their personnel and ensure that dangerous habits are recognized early on. As a result, nurse leaders must provide their staff members the freedom to use their abilities and expertise while still acting morally. For several eyes to spot mistakes and for everyone to feel comfortable pointing out and reporting safety hazards, hospitals must also use their workforce (Battard, 2017). In order to avoid mistakes made during work procedures, nurse leaders must collaborate with frontline nurses to find solutions through candid communication. Therefore, nurse leaders may foster an atmosphere of accountability by involving staff members in the solutions sought as problems are found.

In conclusion

A just culture arises where mistakes are openly discussed to ensure patient safety. Transparency helps staff members and nursing leaders spot and fix systemic problems that could cause medical errors and avert harm. As a result, a just culture is a shared responsibility that should handle every medical issue in a healthcare facility. However, healthcare professionals should be held accountable for preventable errors.

By Day 6 of Week 1

Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days by expanding upon your colleague’s post or suggesting an additional alternative perspective on the role of the DNP-prepared nurse in supporting a just culture in a healthcare organization.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

Submission and Grading Information

Grading Criteria

To access your rubric:

Week 1 Discussion 2 Rubric

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Post by Day 4 of Week 1 and Respond by Day 6 of Week 1

To Participate in this Discussion:

Week 1 Discussion 2

What’s Coming Up in Week 2?

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Next week, you will examine the definitions of quality. You will explore nurse-sensitive quality indicators and evaluate the influence of these indicators on nursing practice.

Looking Ahead: IHI Modules

This Assignment requires completion of 13 IHI Open School modules and the completion of the Certificate of Completion at the Basic level. There are 13 modules that you must complete over the course of these 11 weeks.

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Improvement Capability Patient Safety
QI 101: Introduction to Health Care Improvement PS 101: Introduction to Patient Safety
QI 102: How to Improve With the Model for Improvement PS 102: From Error to Harm
QI 103: Testing and Measuring Changes With PDSA Cycles PS 103: Human Factors and Safety
QI 104: Interpreting Data: Run Charts, Control Charts, and Other Measurement Tools PS 104: Teamwork and Communication in a Culture of Safety
QI 105: Leading Quality Improvement PS 105: Responding to Adverse Events
Triple Aim for Populations Person and Family-Centered Care
TA 101: Introduction to the Triple Aim for Populations PFC 101: Introduction to Person- and Family-Centered Care
Leadership
L 101: Introduction to Healthcare Leadership

To access the IHI Certificate Program, go to IHI.org, and register to create an account. Be sure to enter Walden University as your organization. Under Role, you will select student. Under Organization, you will select school, and under education type, you will select nurse.

Go to the Education tab, and select Open School Courses. Click on Online Courses and then on Certificates and CEUs. You want to ensure that you are viewing the Basic Certificate in Quality and Safety. Click on Earn Your Certificate Today, and you should be in your student dashboard to begin completing the IHI modules. You will want to click on Go to your Learning Center. On the left-side navigation menu, you will want to Search Catalog to search for, and enroll in, each of the 13 modules required for this certificate.

You will earn contact hours for each module, and once all 13 are completed, you will download the certificate of achievement. Please save this certificate. You will be required to upload this to gradebook in evidence of your completion.

You must complete all IHI modules and submit your certificate by Day 2 of Week 11.

Looking Ahead: Clinical Assignment: DNP Project Faculty Advisor and Site Identification

Preparation for project planning will begin during the clinical component of NURS 8302. By Day 7 of week 6, you will identify an organization that you will approach to discuss a gap in practice or practice change that you might assist with as your DNP project.

Possible appointments to explore a site for the project include those made with the chief nursing officer, director of quality improvement, or director of education. In a clinic or community agency, the contact person may be the director or someone in human resources. You may complete the project at your place of employment, as long as you are not working on your own unit or with people that you supervise.

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This project will include a development of a staff education program, development of a clinical practice guideline, or an evaluation of an existing quality improvement process. The project process cannot include patients or nursing students. The project cannot be completed at an academic setting.

Preparation for project planning will begin during the clinical component of NURS 8302. The DNP Project must follow guidelines set forth in one of the following DNP Project manuals:

  • Clinical Practice Guidelines Manual
  • Staff Education Manual
  • Quality Improvement Evaluation Manual 

NOTE: All forms and manuals are found on the DNP Capstone Resources site:
https://academicguides.waldenu.edu/research-center/program-documents/dnp

Your project team will consist of a preceptor or project mentor from the organization, and a three-member Faculty committee from Walden who will be assigned upon completion of this course. You will begin your project in the next term through the mentoring course, NURS 8702.

According to Eng and Schweikart (2020), just culture is a trusting environment in which healthcare personnel is supported and treated fairly when something goes wrong with patient care. Consider the situation in which a nurse discovers that a colleague will give a patient the incorrect medicine dose. She realizes that the drug has been administered before she gets to the patient’s room. She calls the coworker outside to speak with him and informs him that the dosage is incorrect. They debated it and agreed that if medication to prevent an overdose reaction is not given, the patient will most likely face serious side effects. Despite their fear, they gather the courage to inform the in-charge doctor.

The doctor acts promptly and finds a way to stabilize the patient’s health before any catastrophic effects arise. The nurses are then brought to a meeting to discuss how to avoid such incidents in the future and the steps to follow. They are also reminded of the numerous drugs administered in the hospital. The management decides to implement a training matrix that requires employees to attend seminars and workshops to refresh and improve their healthcare knowledge. Employees are encouraged to report any medication delivery errors that could put a patient at risk.

Consider the case where a nurse picks the wrong drug from the dispensing system and gives it to a patient. The patient is in a condition of shock because of the medicine. The nurse is perplexed when she realizes her mistake. She is afraid of losing her work if she reports the incident. The patient dies, and the truth is only found after a postmortem. Even though the nurse is summoned and accepts responsibility for her error, she is fired. Openness, universal and reciprocal accountability, patient-centered care rather than doctor-centered care, perceiving errors as system failures rather than individual faults, and encouraging teamwork are all features of a just culture (Eng & Schweikart, 2020).

In the first scenario, the nurses are entirely transparent. Their decision to tell the truth resulted in saving a life and the improvement of the hospital’s standards. The nurse’s choice in the second case resulted in the death of a patient. He lost his job. If he had followed the correct procedures, she could have saved a life, other people would be motivated to speak up if they made a mistake, and the hospital would have learned from the error and made changes as a result.

Reference

Eng, D., & Schweikart, S. J. (2020). Why accountability sharing in health care organizational cultures means patients are probably safer. AMA J Ethics, 22(9), E779-783. Doi: 10.1001/amajethics.2020.779.

Name: NURS_8302_Week2_Discussion_Rubric

  Excellent90–100 Good80–89 Fair70–79 Poor: 0–69
Main Posting:Response to the Discussion question is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources. Points Range: 40 (40%) – 44 (44%)Thoroughly responds to the Discussion question(s).

Is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources.

No less than 75% of post has exceptional depth and breadth.

Supported by at least three current credible sources.

 Points Range: 35 (35%) – 39 (39%)Responds to most of the Discussion question(s).

Is somewhat reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module.

50% of the post has exceptional depth and breadth.

Supported by at least three credible references.

 Points Range: 31 (31%) – 34 (34%)Responds to some of the Discussion question(s).

One to two criteria are not addressed or are superficially addressed.

Is somewhat lacking reflection and critical analysis and synthesis.

Somewhat represents knowledge gained from the course readings for the module.

Cited with fewer than two credible references.

 Points Range: 0 (0%) – 30 (30%)Does not respond to the Discussion question(s).

Lacks depth or superficially addresses criteria.

Lacks reflection and critical analysis and synthesis.

Does not represent knowledge gained from the course readings for the module.

Contains only one or no credible references.
Main Posting:Writing Points Range: 6 (6%) – 6 (6%)Written clearly and concisely.

Contains no grammatical or spelling errors.

Adheres to current APA manual writing rules and style.

 Points Range: 5 (5%) – 5 (5%)Written concisely.

May contain one to two grammatical or spelling errors.

Adheres to current APA manual writing rules and style.

 Points Range: 4 (4%) – 4 (4%)Written somewhat concisely.

May contain more than two spelling or grammatical errors.

Contains some APA formatting errors.

 Points Range: 0 (0%) – 3 (3%)Not written clearly or concisely.

Contains more than two spelling or grammatical errors.

Does not adhere to current APA manual writing rules and style.
Main Posting:Timely and full participation Points Range: 9 (9%) – 10 (10%)Meets requirements for timely, full, and active participation.

Posts main Discussion by due date.

 Points Range: 8 (8%) – 8 (8%)Meets requirements for full participation.

Posts main Discussion by due date.

 Points Range: 7 (7%) – 7 (7%)Posts main Discussion by due date. Points Range: 0 (0%) – 6 (6%)Does not meet requirements for full participation.

Does not post main Discussion by due date.
First Response:Post to colleague’s main post that is reflective and justified with credible sources. Points Range: 9 (9%) – 9 (9%)Response exhibits critical thinking and application to practice settings.

Responds to questions posed by faculty.

The use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives.

 Points Range: 8 (8%) – 8 (8%)Response has some depth and may exhibit critical thinking or application to practice setting. Points Range: 7 (7%) – 7 (7%)Response is on topic and may have some depth. Points Range: 0 (0%) – 6 (6%)Response may not be on topic and

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