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The Barriers and Enhancers to Trust in a Just Culture in Hospital Settings: A Systematic Review

This systematic review of the literature explored the following question: “What are the barriers and enhancers of trust in the communication of errors by health professionals in a just culture in a hospital setting?”

Only 14 studies met the inclusion criteria. It’s noted that relatively little research into trust and error reporting in just cultures exist. Further, the authors note the challenge of measuring trust, since trust “is a concept that can only be measured qualitatively, not quantitatively” (p7).

Providing background, it’s said that for a long time, most accidents and disasters were attributed to supernatural or religious causes. This changed during the Enlightenment period, where the importance of human reasoning was recognised. This had the effect of shifting blame from Gods to “individual wrongdoing” (p1).

They argue during this shift, there was a period in safety-critical industries where identifying perceived culprits and punishing them was believed to be an effective way to prevent accidents. Notably “this approach does not work, because most accidents are not caused by one or more people but by a series of small events that are insufficient to cause an accident on their own but, if occurring simultaneously, can cause disasters” (p1).

The medical field “also tended to blame individuals”. Philosophies around blame and culpability shifted towards blame-free “cultures”, which eventually led to the Just Culture approaches. Multiple definitions exist, but they define it here as “a patient safety culture in which people can report accidents, incidents, mistakes, errors, and other mishaps without a risk of punishment” (p1).

Creating just environments is said to be challenging and this is partly driven by legal considerations. They argue that “One could say that law primarily looks backward to establish liability, whereas just culture primarily looks forward to establishing future safety (p1).

Another challenge is the tendency to distinguish between acceptable and unacceptable behaviour – said to be the hallmarks of a just culture. However, some, like Dekker and Breaky, suggest that “this is not possible and that emphasis should be put on a restorative approach in which the needs of all stakeholders are addressed” (p1) and focus placed on healing measures rather than drawing lines between acceptable and unacceptable behaviour.

Results

The systematic review resulted in three categories of factors that help or hinder a just culture: organisational factors, team factors, and experience.

1. Organisational Factors

Key findings include:

• Higher management support to nurses in patient safety, the more nurses trust hospital management; improving safety-related comms
• Leadership commitment to safety stimulated trust, e.g. openness of medical directors about near medical misses stimulated trust among staff but management that don’t adequately support physicians taking responsibility for patient safety may erode trust
• Staff trust management more if management look at the whole system rather than blame one individual and if they provide clear explanations how patient safety will be handled
• Uncertainty how management will handle safety reports is a barrier to trust because the system is seen to be ineffective
• Conversational walk-rounds where leaders discuss issues with staff fosters trust whereas surveillance-oriented walk-rounds where executives “check up on frontline staff” creates distrust
• A hospital-wide incident reporting system, where staff fill in reports and the reports are sent off to risk coordinators and then management, was found to create distrust. In contrast, a departmental incident system run by designated healthcare staff was found to improve trust and confidence

2. Team factors

These findings included:

• Close professional relationship between managers and nurses was more effective in creating trust than a “more distant organizational culture” (p6) [*** What I think this alludes to is focusing more specifically on the direct things we think are important rather than something abstract like “cultures”]
• Trust was more likely enhanced when “so-called violations” of trust resulted from a perceived lack of ability rather than a lack of integrity
• Defining clear roles of health professionals in a team makes it easier for people to ask questions about patient safety [*** which I believe alludes to breaking down power gradients]
• E.g., physicians often move between departments but are “still expected to be part of a multi-professional team. If there is no clear definition of everyone’s role, it is difficult for team members to have a shared view about patient safety” (p6).

3. Experience-related factors

These factors included:

• Experienced staff are more likely to report issues compared to novices. Further, more experienced trainees believe whistleblowing is vital for protecting patient safety compared to more novice trainees
• One study found that experience influenced the “willingness to admit and talk about errors” (p6), where less-experienced physicians discussed errors less openly
• 1^st year residents experienced more barriers to speaking up (29%) compared to 3^rd/4^th year residents (12%)
• Barriers also included the lack of knowledge on how to speak up and a lack of confidence in clinical skills [*** this is also evident in industries like construction]
• Another study highlighted that frontline workers are often afraid to report errors, with 12% feeling shame and 32% fearing blame. In contrast, supervisors and senior managers are less afraid of being blamed (~10 to 19%) [*** this alludes in my view to how there’s “power in safety” and “safety in power” to quote Dekker et al. and how it helps to be able to draw the line in the sand in the management position about acceptable/unacceptable behaviour]

Authors then discuss the findings. They note the finding about the negative effect of a hospital-wide reporting system on trust, compared to the departmental-level reporting system, which enhanced team confidence. This is because it was run by peers and directly used to improve medical procedures and practice.

The hospital-wide system was seen as a “managerial and nonmedical approach” and thus “faceless” (p.7). Moreover, the external/managerial interventions resulting from the hospital-wide reporting system resulted in “limited belief that meaningful improvements would be made to services” (p7).

Organisational openness about how error reports are handled can also enhance trust by “taking away the perception of an ineffective system in which no action is taken on error reports” (p7). Managers here have a profound influence on error communication, and their attitude, commitment and openness are essential to fostering trust.

In contrast, if “executives check up on staff, staff tend to cover up or hide mistakes” (p7). A conversational approach better fosters a close relationship.

It’s noted that interprofessional meetings can bring issues about distrust into the open; fostering trust.

Finally, a willingness and fostering for more experienced staff to discuss their own errors, incidents, insights, workarounds etc. increases the confidence for less experienced staff to speak up and thus, “making them feel less inept or that they do not meet perceived professional standards” (p7).

In concluding, they state that trust is essential for instigating a just culture experience and “trust can be learned and created based on practical principles” (p7).

Authors: van Marum, S., Verhoeven, D., & de Rooy, D. (2022). Journal of Patient Safety, 10-1097.

Shout me a coffee

Study link: https://doi.org/10.1097/PTS.0000000000001012

Link to the LinkedIn article: https://www.linkedin.com/feed/update/urn:li:ugcPost:6939696327932940288?updateEntityUrn=urn%3Ali%3Afs_updateV2%3A%28urn%3Ali%3AugcPost%3A6939696327932940288%2CFEED_DETAIL%2CEMPTY%2CDEFAULT%2Cfalse%29