Enhancing Patient Safety: The Infusion of Just Culture Behaviors into the Student Clinical Experience

The role of nursing faculty is to create a learning environment where students gain the knowledge, skills, and attitudes necessary to provide safe care to patients. One strategy to enhance safer care is to infuse principles of a just culture into the curriculum of a pre-licensure nursing program. Principles of a just culture include: fostering an atmosphere of trust, encouraging error and near-miss reporting, recognizing that there are clear lines between acceptable and unacceptable behaviors, and promoting learning from errors. The American Nurses Association supports just culture initiatives for improvement of patient safety (ANA, 2010).

Faculty must model and instill in students the commitment to lifelong learning, improvement, and understanding of safe care (Caputi, 2014). Benner’s (1984) seminal work on how nurses progress from novice to expert nurses remains relevant, even in the face of significantly more complex health care and systems of delivery. Faculty need to keep pace with this changing environment and prepare students to identify and solve problems for effective and safe nursing practice. Nursing faculty must be cognizant of the expectations of healthcare organizations put forth by The Joint Commission to become learning organizations in which a fair and just safety culture exists, (The Joint Commission, 2015) then ensure that graduates from their program will be prepared to function well in such an environment. However, the literature reveals few schools of nursing who have integrated a just culture into the curriculum and the process whereby this was accomplished. Therefore, a pervasive spirit of inquiry and willingness to innovate among faculty was necessary for the infusion of just culture to be successful.

Clinical faculty within a School of Nursing in a private, religiously affiliated university in the southeastern United States, were taught to promote and practice a just culture with students in the clinical setting. Curriculum modification was directed toward building a framework to include the knowledge, skills, and attitudes of a just culture. Dissemination of and instruction on these modifications was accomplished through both face-to-face and electronic educational modules.

Knowledge:

Clinical faculty were provided with objectives and learning outcomes aimed at an appreciation for and comprehension of just culture.   They were given access to a Clinical Café housed on the university’s open-source learning platform. Narrated PowerPoint educational modules were created that defined and described the theory and concepts of a just culture (Leonard & Frankel, 2014a).  Just culture policies were developed that included expectations for student reporting of errors and near-misses as well as guidance for faculty responses at the time of these occurrences. 

Skills:

An algorithm (Leonard & Frankel, 2014b) was utilized to guide clinical faculty in assessment and decision-making about those involved in errors or near-misses.  Participants were taught to systematically follow the worksheet in formulating appropriate responses to reckless, risky, or unintentional actions. Use of the algorithm was facilitated with a “train-the-trainer” method with the authors and clinical faculty. Skill development for evaluation of student behaviors, level of intent, system influences, and judgment of culpability or possible discipline was guided by means of practice sessions that involved unfolding scenarios in which errors and near-misses occurred. A reporting system for errors and near-misses experienced or observed by students was instituted with reassurance that students would have their identity protected, and that errors or near-misses could, with student permission, be discussed in a blame-free environment.

Attitudes:

Psychological safety for each student was an essential component of just culture within the debriefing sessions held during clinical post-conference. Transparency was encouraged and commended for the purpose of a learning experience that would benefit all participants.

The expected outcome of embedding a fair and just culture within the School of Nursing is that students will gain trust as they are encouraged to openly share, by means of a reporting mechanism, in a non-punitive environment. As students matriculate through the curriculum, then graduate and go into practice, they will be more cognizant of personal, environmental, and system irregularities that potentially lead to patient harm and better recognize their responsibility in reporting so that corrections and adjustments can be made. A heightened awareness of how errors occur may lead to a safer environment for the patient.