Glitches are a natural component of every human institution, including work productivity. Even modest errors can have catastrophic consequences in specific high-risk sectors, such as medicine, nuclear energy, aerospace, and passenger trains. When pediatricians, pharmacists, psychiatrists, and other front-line professionals make even slight errors during care coordination, the repercussions can be costly, lasting, or even lethal (Paradiso & Sweeney, 2019). These errors can be as basic as medicine infusion mistakes or bedside service issues such as failing to turn bedridden patients on time to prevent bedsores. Just Culture understands that mishaps are frequently the result of system failures and promotes the documentation of near-misses and outright incidents to promote ongoing process effectiveness (Paradiso & Sweeney, 2019). To foster a just work environment, administration and corporations must cultivate trust in their interactions with every component of the healthcare system. This paper aims to explain the crucial function of a Just Culture in ensuring patients’ effectiveness, quality of care, and well-being. Additionally, the technique of assisting the individual who committed the mistake, referred to as the second victim, will be described as a critical element.
Impact of a Just Culture on Quality and Safety
A Just Culture institution analyses the system that surrounds an individual’s behavioral decision and, when appropriate, optimizes procedure architecture to mitigate risk. Just Culture aims to increase disclosure of mishaps, harmful occurrences, and near misses by removing responsibility for human mistakes, enabling the institution to learn from its errors (Edwards, 2018). By contrast, policies that prioritize interpersonal sanctions over system improvement create substantial opportunities for people to reveal only those infractions that cannot be concealed (Edwards, 2018). Concurrently, Just Culture aims to retain responsibility for behavioral decisions by using a mechanism for distinguishing between faultless and blameworthy activities (Edwards, 2018). A transparent and Just Culture promotes patient efficiency by evaluating the environment and contributing to worker protection activities (Edwards, 2018). Enhancing patient safety mitigates risk by emphasizing regulating people’s behavior or assisting others in moderating their behavior, as well as system reform (Edwards, 2018). Professionals in a Just Culture are found liable for their decisions and actions and those of their peers, which may enable them to transcend their natural aversion to functioning with disabled or ineffective coworkers.
A Just Culture enables the development of a favorable healthcare quality profile in response to external auditors like The Joint Commission. It considers the possibility of rejuvenating the morbidity and mortality convention to foster collaboration across specialties and the development of a patient-centered emphasis (Rogers et al., 2017). Additionally, a Just Culture proposes a concept of shared responsibilities that is values-based (Rogers et al., 2017). This Culture holds healthcare institutions answerable for the processes they establish and their appropriate responses to employee behavior.
Balanced responsibility enables the complex risks inherent in medical coverage to be managed. Shared responsibility necessitates the incorporation of the perspectives of staff from diverse specialties into a compelling experience (Rogers et al., 2017). Incorporating personnel significantly in this approach motivates them to take accountability for their activities and enhance obligation when mistakes occur. This collective commitment also extends to patient safety statistics openness (Rogers et al., 2017). If enterprises want to involve their personnel in system effectiveness activities, they must also be comfortable providing their overall flaws. All workers should be informed regularly of fault patterns and system breakdowns.
Just Culture and the Second Victim
The terminology second victim refers to the effect that unfortunate occurrences have on medical practitioners. They may suffer mental health difficulties such as humiliation, remorse, stress, despair, and melancholy (Werthman et al., 2021). Additionally to the emotional reaction, individuals endure cognitive impairments such as disappointment, tiredness, and anxiety symptoms (Werthman et al., 2021). Healthcare practitioners actively engaged in unpleasant occurrences are likely to experience emotional consequences, manifest as insomnia, regret, low confidence, humiliation, panic, or decreased job contentment (Werthman et al., 2021). If left untreated, they can have various negative repercussions, including melancholy, emotional weariness, and suicidal behavior.
A stage toward the healing of the second victim is to seek emotional emergency aid. As a result, the medical professional will seek guidance from others. Although the healthcare practitioner may seek to rely on others, such as professional colleagues, acquaintances, relatives, or others, ambiguity as to who to turn to persists (Bleazard, 2019). Attempts to confide in someone outside the clinical setting, such as significant others, may end fruitless. Moreover, moral and constitutional constraints for the sharing of patient-related knowledge may deter second victims from accessing emotional comfort from those not within the therapeutic setting (Bleazard, 2019). Involving the second victim in recognizing the system issue that resulted in their mistake is a critical method for assisting them and alleviating emotions of guilt.
They must believe that their medical team collaborates with them to address a broader issue rather than dismissing them as incapable. It is critical to build a sense of cooperation immediately because it can be quite unpleasant to revisit the experiences with numerous others in the future (Bleazard, 2019). Additionally, this method reassures the victims that they are not alone and that the organization will not penalize, condemn, or forsake them during this susceptible moment.
Reflection on Group Work and Case Study
Our group used scenario #2, where an EVS waxed floors in buildings around 10.00 pm. However, he could not locate the wet floor sign and was forced to move to another facility in search of one. Confident he was alone in the building, he did not search for a warning sign. Sometime later, a physician slipped on the wet floor and severely damaged her knee. The physician was angry with the EVS worker because her injury would result in missing work time. The maintenance team was always on the lookout for damp floor red flags, which resulted in them falling behind on their task. The EVS administrator was conscious of the shortage of indicators but took no steps to procure additional ones.
Based on the Just Culture Process Model, the group agreed that the EVS worker is consoled as the second victim. Despite his numerous efforts to locate the wet floor sign within the building, he was unable to. While the clinician may have been harmed and enraged at the EVS employee, he was not at blame in particular since the EVS supervisor was mindful of the lack of wet floor warnings but made no attempt to fix them. Therefore, the EVS worker should be counseled and offered emotional support. The EVS manager must have been aware of the risks associated with the wet floor, yet he ignored replacing the wet floor signs that, to his attention, he knew were lacking within the building. Therefore, we concurred that the EVS supervisor committed a careless infringement, which merits disciplinary measures in the face of a negative assessment and a caution that the behavior should not be repeated, following the Just Culture Process Model’s suggestions.
However, some group members felt that the physician was too aggressive with the EVS worker, who was not at fault, thus aggravating her anger towards the worker was inappropriate and therefore practicing high-risk behavior. I initially thought that the EVS worker must have conducted an error of negligence but did not utter a word. The other group members had much compassion for the EVS worker. I began by following the methodological framework and determining how his contribution to the mistake fell within the section of no obligation. I also observed how he was a target of the practitioner’s coercion following the group consultation.
It was somewhat challenging to maintain objectivity throughout determining culpability and arranging appropriate corrective proceedings for each individual. The group decided that the EVS manager should immediately purchase the wet floor signs since different people use the building daily to prevent a similar case like that of the physician. Nonetheless, the Just Culture approach paradigm enables us to stand back and assess the processes and decisions at play to take appropriate remedial measures neutrally and impartially when appropriate.
In conclusion, glitches are a natural component of every human institution, including work productivity. Therefore, Just Culture understands that errors are frequently the result of system failures and promotes the documentation of near-misses and outright incidents to promote ongoing process effectiveness. Additionally, the nurse practitioner can decrease the consequences of unfavorable patient occurrences on second victims, including emotional weariness, post-traumatic stress disorder, recurrent adverse outcomes, staffing turnover, job unavailability, and melancholy.
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Edwards, M. T. (2018). An assessment of the impact of just Culture on quality and safety in US hospitals. American Journal of Medical Quality, 33(5), 502-508.
Paradiso, L., & Sweeney, N. (2019). Just Culture: It’s more than policy. Nursing Management, 50(6), 1-8.
Rogers, E., Griffin, E., Carnie, W., Melucci, J., & Weber, R. J. (2017). A just culture approach to managing medication errors. Hospital pharmacy, 52(4), 308-315.
Werthman, J. A., Brown, A., Cole, I., Sells, J. R., Dharmasukrit, C., Rovinski-Wagner, C., & Tasseff, T. L. (2021). Second Victim Phenomenon and Nursing Support: An Integrative Review. Journal of Radiology Nursing, 40(2), 139-145.