The fusion of Magnet^® principles and just culture can produce a global healthcare culture focused on creating safer healthcare systems through disclosure, transparency, and public reporting. Just culture propels transparency to the forefront by straddling the divide between punitive and blame-free error-reporting systems. It acknowledges that competent professionals can make mistakes. If they do, it doesn’t punish them for these errors, as long as the errors are commensurate with their experience and training. By the same token, just culture doesn’t tolerate willful violations, reckless behavior, or gross negligence.
Just culture promotes disclosure of healthcare errors through collaboration, proportional accountability, intense self-evaluation, and decency. Exploring the relationship between Magnet components and just culture helps us understand the timely necessity of the shift to just culture in health care. (See Behaviors that contribute to errors by clicking the PDF icon above.)

Significance of Magnet^®

The Magnet Recognition Program^® has become the apex of achievement for nursing professionals and healthcare organizations. Magnet designation is the pinnacle of nursing achievement and organizational nursing success, denoting the organization has attained excellence in both nursing practice and practice standards. Achieving Magnet designation means the facility has created an infrastructure of interdisciplinary care that successfully integrates best practices, fosters the highest quality of care, and produces unprecedented patient-care outcomes while promoting collaboration and shared decision making.

Magnet hospitals report higher levels of nurse and patient satisfaction, improved quality of care, reduced error rates, fewer patient falls, decreased hospital-acquired pressure ulcers, and lower mortality rates. Not surprisingly, they report better patient outcomes than non-Magnet hospitals and tend to rank in the top 10% for excellence throughout the nation. Nurses in Magnet facilities are more likely to report errors and participate in error-related problem-solving because they feel empowered by the organizational culture and have supportive relationships with senior administrators.

Studies of Magnet facilities indicate they promote exceptional patient outcomes and have shorter lengths of stay, reduced occupational injuries, and decreased nursing turnover. What’s more, they’re able to recruit outstanding experienced nurses, which can translate to lower overall operational costs.

Understanding just culture

Just culture seeks to mitigate system failures in organizations with inherently high risk levels, such as healthcare facilities, because they’re operated by human beings—all of whom are fallible. Just culture promotes organizational learning by accepting that mistakes will happen, creating accountability by identifying behaviors that inherently expose organizations to risk, and building resilience by promoting industry safety.

Organizations that adopt the just culture model accept that errors will occur with and without negative outcomes. Each type of error is equally important to disclose because identifying and reporting errors builds trust and promotes transparency, high-quality care, and patient safety. Just culture embraces system failures, errors, and weaknesses for the purpose of turning them into educational opportunities for improvement and learning. (See Pioneers of just culture theory by clicking the link above.)

Just culture is not a nonpunitive error-reporting system. It doesn’t negate individual responsibility or organizational liability. Adopters of just culture recognize that errors demand serious investigation and critical evaluation of facts to prevent future errors. In just culture, counseling, remediation, termination, and possible criminalization of errors are possibilities. Just culture seeks to promote organizational commitment to universal safety in health care by increasing awareness, self-awareness, error-reporting education, better performance, and industry compliance.

Creating trust

Implementing a just culture that includes and expects disclosure and reporting from all employees creates trust within a healthcare facility. Trust must be promoted and demonstrated at all organizational levels. It helps eliminate barriers to disclosure, such as fear of punitive action, retribution from senior leaders and coworkers, criminalization of errors, and social isolation from colleagues. According to one study, 40% of clinicians were too intimidated to report errors; nonclinicians were more likely to report errors than frontline caregivers.

Just culture unites employees by creating shared responsibility in the pursuit of patient safety,
in­creasing the quality of care and awareness, promoting nurse retention through trust, strengthening morale among staff members pursuing excellence as a team, and maximizing opportunities for organizational learning. Just culture transforms every mistake and error into an opportunity to learn for the purpose of improving patient outcomes across the entire organization.

Translating just culture into Magnet readiness

Facilities seeking to achieve Magnet recognition should strive to integrate just culture concepts with the five Magnet components, as described below. Success in all five components may provide the evidence necessary to support Magnet readiness.

Structural empowerment

Magnet recognition is granted to organizations that (among other things) create an infrastructure of collaboration among all staff members and foster a culture of shared decision making. According to one article, nurses who worked for Magnet organizations felt more empowered, more satisfied with their work, and more able to contribute to the organization as a whole; they also were more likely to report problems. Nurses who feel supported and empowered by their managers and organizations are more likely to stay at their current place of employment.

Exemplary professional practice

Just culture has the potential to increase hospital employee retention; to reinvent nurse administrators through a deeper understanding of transparency, disclosure, and public reporting; and to establish the foundation for transforming nurse satisfaction. It promotes personal development through critical self-evaluation and mastery of awareness while creating better opportunities for achieving Magnet status and delivering high-quality patient care.

Staff nurse retention is a major consideration for achieving Magnet status. Staff turnover can decrease permanent staff satisfaction because it necessitates the use of per diem nurses, registry nurses, and traveling nurses. Magnet facilities tend to employ more experienced nurses with higher educational levels; these facilities have less nurse turnover and lower morbidity and mortality rates.

Transformational leadership

Leadership skills and management styles influence all aspects of nursing care because of the amount of time nurse managers and nurse administrators spend with frontline nurses and their ability to empower and engage staff. One study reported that employees’ opinions of their nurse managers or supervisors had greater impact on their intent to stay with an organization than their satisfaction with the organization itself. An Australian study found that nurses’ morale was greatly influenced by the nurse administrator and had a huge impact on retention, turnover, workplace health, quality of care, and safety. Nurse administrators must have substantial knowledge of their organization to create opportunities for change and enhance programs and processes that create a culture of shared governance and commitment.

New knowledge, innovations, and improvements

ew knowledge is one of the greatest benefits of just culture. Exposing errors, mistakes, and weaknesses in patient care and health delivery promotes opportunities for the entire organization to learn and create more positive patient outcomes. Just culture fosters innovation and improvements by investigating errors and designing systematic efforts to prevent future errors.

Empirical quality results

Empirical quality results demonstrate the delivery of high-quality care in hospitals and healthcare systems.

Aligned for patient safety

The quest for Magnet recognition and implementation of just culture are unmistakably desirable in an industry fraught with risk, mistakes, and fatal errors. Magnet components and just culture concepts are well aligned for fusion. This unique alignment promotes a global healthcare culture shift focused on constructing vital healthcare systems through disclosure, transparency, public reporting, professional development, advancement of nursing and medical science, and shared decision making. It unites clinicians and nonclinicians alike for the purpose of improving patient safety.

Selected references

Aiken LH, Clarke SP, Sloane DM, Lake ET, Cheney T. Effects of hospital care environment on patient mortality and nurse outcomes. J Nurs Adm. 2008;38(5):223-229.

Brous E. The criminalization of unintentional error: implications for TAANA. J Nurs Law. 2008;12(1):5-12.

Hughes LC, Chang Y, Mark BA. Quality and strength of patient safety climate on medical-surgical units. Health Care Manage Rev. 2009;34(1):19-28.

Leape L, Berwick D, Clancy C, et al; Lucian Leape Institute at the National Patient Safety Foundation. Transforming healthcare: a safety imperative. Qual Saf Health Care. 2009;18(6):424-428. doi:10.1136/qshc.2009.036954.

Mayer CM, Cronin D. Organizational accountability in a just culture. Urol Nurs. 2008;28(6):427-430.

Reason J. The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries. Surrey, United Kingdom: Ashgate Publishing Company; 2008.

Wolf G, Triolo P, Ponte P. Magnet recognition program: the next generation. J Nurs Adm. 2008;38(4):200-204.

Erin Shannelle Bashaw is a medical-surgical nurse at ValleyCare Health System in Pleasanton, California.