Examine an adverse event at the unit level in your organization or one with which you are familiar and apply the Regulatory Decision Pathway.

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Discussion: Making the Case for Capital

Discussion: Group Management for Just Culture

The concept of a fair and just culture refers to the way an organization handles safety issues. Humans are fallible; they make mistakes. In a just culture, ‘hazardous’ human behavior such as staff errors, near–misses and risky actions are identified and discussed openly in hopes of finding ways to improve processes and systems—not to identify and punish the individual.
—Pepe & Caltado, 2011

This Discussion examines the opportunities of managers in working with groups to promote change that facilitates the delivery of safe, high–quality care.

To Prepare

  • Review the information on just culture presented in the Learning Resources.
  • For this discussion, you will use the Regulatory Decision Pathway found in Russell, K. A. & Radtke, B. K. (2014).
  • Examine an adverse event at the unit level in your organization or one with which you are familiar and apply the Regulatory Decision Pathway.
  • Compare the findings of the Regulatory Decision Pathway  to what actually happened at the unit in your organization. Was the event deemed: bad intent, reckless, at risk, or human error? According to the pathway, do you now think it was the correct action?
  • Think about how a nurse leader–manager may use just culture as a framework to create or maintain a focus on accountability and outcomes throughout a group. What actions could be taken if a systems–related error was made or if an error resulted from risky behavior?
  • How might role conflict and/or ambiguity have contributed to the situation?
By Day 3

Post a description of an adverse event in your organization and your analysis of the issue using the Regulatory Decision Pathway. Explain how role conflict or ambiguity might have influenced this situation. Apply the principles of just culture as you explain how you, as the group’s manager, would handle the situation.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on two different days using one or more of the following approaches:

  • Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.
  • Offer and support an alternative perspective using readings from the classroom or from your own research in the Walden Library.
  • Validate an idea with your own experience and additional research.
  • Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.

Reference
Pepe, J., & Cataldo, P. J. (2011). Manage risk, build a just culture. Health Progress. Retrieved from http://www.outcome–eng.com/wp–content/uploads/2012/01/manage–risk.pdf
Russell, K. A. & Radtke, B. K. (2014). An evidence–based tool for regulatory decision–making: regulatory decision pathway. Journal of Nursing Regulation, 5(2), 5–9.

Marquis & Huston, Leadership roles and management functions in nursing, 2015