The OR and a “Just Culture”

Inadequate Communication 

Teamwork is a fundamental aspect of care delivery in the OR, and it is embedded within the culture of the perioperative environment. That said, some could be forgiven for thinking that the surgical team is a fixed or stable corpus, when, in fact, it is a dynamic, fluid, nonconstant entity, membership of which is often transitory. On occasion, the “surgical team” seems nominal only, so nebulous is membership.8

The performance of the team is influenced by social relationships and communication patterns, and exploration of these factors has produced some unhappy findings. The varying ways that members of the relevant disciplines (eg, nurses, surgeons, anesthesiologists) are socialized into their communities of practice, beliefs about their roles and the roles of others in the OR, and different communication styles and foci are now well-documented; these can be sources of confusion and conflict.8 Inadequate or inappropriate communication is commonplace among surgical team members and can have significant—even disastrous—consequences for patients, including surgical delays and cancellations, wrong site surgery, and surgical items unintentionally left in patients. Many of these errors have been associated with communication breakdown of one type or another.7

Disruptive Behaviors 

Verbal abuse is another aspect of interpersonal communication among OR team members. Perioperative nurses continue to experience verbal abuse from colleagues, managers, and medical staff members. Associated with verbal abuse are workplace bullying; harassment and horizontal (ie, lateral) violence; and other disruptive behaviors.8, 9 The manifestations of these facets of workplace violence—such as overruling of decisions, undervaluing or belittling of colleagues, withholding of information, and sabotaging to name but a few—are commonplace in the OR. Such inappropriate behaviors limit the extent to which individuals can both practice and participate as team members.8, 10

Disruptive behaviors have a significant effect on team dynamics and communication, can have a negative effect on patient care, and are deleterious for perioperative nurses and other staff members. They also reflect a poor workplace culture. What to do?

Improving the Culture 

One approach to improving workplace culture is to address organizational culture in a wider context and to develop a just culture.11 The just culture concept teaches us that we need to move away from retrospective examination and judgment of others that is focused on the severity of an adverse outcome experienced by a patient to a rational and systematic evaluation of behavioral choices. A just culture is one in which frontline personnel feel comfortable disclosing errors and acknowledging their mistakes.11 It produces an open and fair workplace where each participant maintains dignity and receives respect.12

Traditionally in the health care culture, individuals are held accountable for all mishaps and errors that befall their patients. In contrast, in a just culture, it is recognized that individual health care professionals should not be held accountable for system failings over which they have no control and that many individual errors represent predictable interactions between human operators and the systems in which they work. It is the employer who is accountable for the facility's systems and for supporting safe choices by patients, visitors, and staff members.

That said, a just culture is not one in which the governing principle is that of “no blame” because a just culture does not tolerate conscious disregard of risks to patients, nor does it condone misconduct. Employees are accountable for the quality of their choices rather than the severity of the outcomes when an error is made, but it is recognized that competent professionals make mistakes. In summary, a just culture is characterized by learning from mistakes; openness and frankness; robust, safe systems; and the management of behavioral choices.12

Implementing a Just Culture 

Consider the following hypothetical example. In conjunction with key perioperative personnel, a hospital's senior management team decides to implement the World Health Organization (WHO) Surgical Safety Checklist.13 The administrators develop clear and unequivocal guidelines (ie, a “procedural rule”) about the behavior required of all perioperative personnel (eg, anesthesiologists, nurses, surgeons, surgical technologists). It is mandatory that personnel use the checklist for all surgeries to produce a desired outcome, that of safe surgical interventions. The new procedural rule is communicated to all relevant personnel; additionally, the administrators provide resources, such as staff training on use of the checklist, to aid in its implementation. Subsequently, all perioperative personnel have a duty to use the checklist (ie, to follow the procedural rule).

A procedural rule may be inadvertently violated (eg, by a new circulating nurse who is unaware of the use of the WHO checklist) or knowingly violated (eg, by an aggressive surgeon who refuses to participate in all phases of the checklist). A single instance of non-use would lead to the perioperative staff member being counseled, and the hospital would seek to understand what human factors led to the rule violation.

In a just culture, the perioperative staff member who had a good faith belief that the violation was justified would be considered to have engaged in risky behavior; the behavior would be investigated to understand its source (eg, the new circulator had not been made aware of the checklist); and the staff member would be coached (eg, the new circulator would be educated on use of the checklist). However, if the health care professional did not have a good faith belief in the justification for the violation (eg, the aggressive surgeon believes the checklist “is a waste of time”), he or she would be dealt with for reckless violation, and punitive action might be necessary. In a just culture, when an incident occurs that causes harm or puts another at risk of harm (eg, failure to follow the checklist, increasing the chance that a surgical patient will experience wrong site surgery), the person's motivation or purpose would be investigated (eg, the surgeon was very busy). The behavior would need to be assessed against the objective standard of whether a similarly situated person (eg, another surgeon) would have seen the risk and appreciated it as being substantial and unjustified. Repetitive risky behaviors must be analyzed carefully and purpose-designed solutions identified (eg, coaching for the offending surgeon by a senior member of the hospital's surgical council). Punitive action may be required (eg, cancellation of the offending surgeon's privileges at the hospital).

Implementing a just culture is not for the faint-hearted. It requires incorporation of the just culture language into organizational policies related to employees, job descriptions, medical staff bylaws, and codes of conduct, including disciplinary procedures and consequences. This can take several years; however, I believe it is an approach that will resonate with all perioperative nurses given our commitment to patient safety, our need to respect each other, and our entitlement to be respected.