1. Just Culture: The Necessary Environment for Safe Practice Sally Watkins, PhD, RN Assistant Executive Director Nursing Practice, Education, and Research Washington State Nurses Association

2. Objectives What is a just culture? What steps can you take to embed a just culture in your work environment? What is WSNA doing to help establish such a culture of safety in the workplace?

3. It is from the mission of caring for people in times of their greatest vulnerability and need that health care workers find meaning in their work, as well as their experience of joy. Lucian Leape Institute

4. Yet, many suffer emotional & physical harm while providing care: Bullied Harassed Demeaned Ignored Physically assaulted Physically injured

5. Workplace safety is inextricably linked to patient safety. Unless caregivers are given the protection, respect, and support they need, they are more likely to make errors, fail to follow safe practices, and not work well in teams.

6. Care is complex…mistakes are inevitable…. Physicians Insurance A Mutual Company

8. So…what’s the “old” culture? Name, blame, shame Fear – of retaliation, of termination Culture of silence Loss of licensure/ability to work Lack of administrative accountability for system issues Other?

9. Characteristics of a Just Culture Atmosphere of trust & respect Teamwork: “Have each other’s backs” Encouragement for disclosure Learning environment Accountability for behaviors but not system failures Recognition that humans do make mistakes; non-punitive response Leadership competency alignment

10. A just culture accepts nobody’s account as “true” or “right” and others wrong…Instead it accepts the value of multiple perspectives, and uses them to encourage both accountability and learning. Sidney Dekker

14. Differentiate: Human error At risk behavior/negligence Reckless conduct Intentional rule violation »Disciplinary Systems Theory David Marx, JD

15. What steps can you take to embed a just culture in your work environment?

16. Personal Leadership Mindfulness Creativity

17. Encouraging consciousness Suspend judgment Engage ambiguity Invite reflection Acknowledge “something’s up”

18. Clinical Forethought Anticipating and preventing potential problems “Future Think” – forethought about specific diagnoses Anticipation of crises, risks, and vulnerabilities Seeing the “unexpected” Benner, Hooper-Kyriakidis, and Stannard

19. QSEN Competencies Quality Improvement Safety Teamwork and Collaboration Patient-centered Care Evidence-based Practice Informatics KNOWLEDGE SKILLS ATTITUDES

20. Nurses routinely skip breaks & meal periods to provide patient care Ann Rogers, PhD, RN, FAAN

21. Self-scheduling controls Take your breaks Nourish your body Power naps Look at number of hours, shifts, days in a row Take your vacations

22. Fatigue is a source of error Decreased alertness Decreased vigilance Decreased concentration Decreased judgment Depressed mood Impaired performance Increased anxiety

23. Assess your fatigue risk Epworth Sleepiness Scale (ESS) The Pittsburgh Sleep Quality Index (PSQI) www.wsna.orgwww.wsna.org – Practice - Fatigue

24. Johns, M.W. (1991). A new method for measuring daytime sleepiness: The Epworth sleepiness scale. Sleep, 14, 540-545. EPWORTH SLEEPINESS SCALE 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing Sitting and reading Watching television Sitting inactive in a public place (e.g. a theater or meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in the traffic

25. Workplace engagement Do you know your department’s quality indicators and result trends? Do you participate in debriefings? Disclosure processes? Do you attend staff meetings? Are you on a committee? DON’T GOSSIP - “Nothing about me without me” philosophy re: colleagues Provide “second victim” support Report near misses, unsafe staffing

26. What else can YOU do? (WWFD) : Moral Courage! Speak of up for safety using ARCC: Ask a question Make a Request Voice a Concern (“I have a concern…”) If no success, use Chain of Command ARCC from Craig Clapper, HPI)

27. WSNA’s activities to promote just culture Proposed legislation Continuing education Resources Coalition partnerships

28. The incentive of having a just culture is to feel free to concentrate on doing a quality job rather than on limiting personal liability, to feel involved and empowered to contribute to safety improvements by flagging weak spots, errors and failures. Sidney Dekker

29. To find joy & meaning in your daily work, you must be able to answer “YES” each day: Am I treated with dignity & respect by everyone? Do I have what I need so I can make a contribution that gives meaning to my life? Am I recognized and thanked for what I do?

30. References ANA Position Statement “Just Culture” 2010 Barnsteiner, J. (September 30, 2011) Teaching the Culture of Safety. OJIN: The Online Journal of Issues in Nursing. Vol 16, No 3, Manuscript 5. Benner, P, Hooper-Kyriakidis, P & Stannard, D (2011) Clinical wisdom and interventions in acute and critical care. A thinking-in-action approach (2 nd ed.) NY, NY: Springer Publishing Company. Dekker, Sidney. (2012) Just Culture. Ashgate Publishing Company Johns, M.W. (1991). A new method for measuring daytime sleepiness: The Epworth sleepiness scale. Sleep, 14, 540-545. Lucian Leape Institute. (2013) Through the eyes of the workforce: Creating joy, meaning, and safer health care. National Patient Safety Foundation: www.npsf.org NCSBN Regulatory Action Pathway. From NCQAC March 2013 Agenda. Schaetti BF, Ramsey SJ, & Watanabe GC. (2008) Personal Leadership. Seattle, WA: Flying Kite Publications The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents http:www.ahrq.gov/downloads/pub/advances/vol4/Meadows.pdf