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How a “just culture” can improve safety in health care


In April, reports surfaced of air traffic controllers asleep on the job. Frightening audio clips of airline pilots hearing nothing but silence from the control tower went viral, which were quickly followed by calls for immediate firings, resignations from officials at the Federal Aviation Administration (FAA), and plans for congressional hearings. Anger and fear were the day’s watchwords.

But the initial uproar and calls for rash action point to a bigger problem for many industries, including health care. As these recent incidents demonstrate, worker fatigue and a “blame culture” are still major impediments to quality and safety.

Fatigue has long been a concern for the National Air Traffic Controllers Association (NATCA). Most of the incidents for the dozing air traffic controllers occurred on overnight shifts, and in some cases, where the night shift controller was on duty alone. In response to the events, NATCA President Paul Rinaldi said in a statement:

“For more than a decade NATCA has expressed its deep concerns about increasing controller fatigue. Our national constitution calls for the ending of single staffing on the midnight shift and for years we have lobbied past Administrations and Congresses on the need to find solutions to controller fatigue before it is too late.”

This is a stark parallel to the concerns about nurse fatigue. Working night shifts, rotating schedules, mandatory or voluntary overtime, and long shift hours can take a toll on nurses. And the effects of nurse fatigue on patient and occupational safety are well documented. There have been calls for elimination of 12-hour shifts for nursing based on evidence that they are too long in duration.

Like air traffic controllers, nurses are professionals, and have obligations to avoid working fatigued if they can, and to advocate for workplaces that prevent worker fatigue. ANA has official position statements on nurse fatigue, which address the responsibilities of the nurse and the employer in guarding against fatigue. Nurses are guided by their ethical and professional duties to consider how multiple jobs or voluntary overtime shifts could impact their ability to practice safely. ANA calls on employers to implement workplace policies that help alleviate worker fatigue, thereby ensuring patient and worker safety is not compromised. Other resources for nurses on fatigue are ANA’s position statement “Patient Safety: Rights of Registered Nurses When Considering a Patient Assignment, and the Principles for Nurse Staffing.

Nursing is not alone in the healthcare professions in being concerned about working too many hours. Traditionally, medical residents worked very long hours, and even when off-duty, were considered “on call.” Most nurses have probably experienced working with a bleary-eyed resident that had been on duty for more than 24 consecutive hours. But through evidence of potential or real harm to patients, an Institute of Medicine report challenged that traditional notion that more was better in terms of hours of education. Subsequently, the medical education accrediting body issued guidelines that restricted the number of hours a resident could be on duty to a maximum of 16 hours per day, and 80 hours per week.

The blame game

But one of the critical pieces of these recent events is that while blaring headlines of sleeping air traffic controllers led to calls for immediate firings, this is part of a “blame culture.” It may be instinctive to seek immediate punishment, but this paradigm is actually counteractive to preventing these types of mishaps. Nurses may have experienced this knee-jerk reaction in their practices, such as a nurse being immediately disciplined for a medication error.

In place of this, ANA is among the advocates for the use of the “just culture” concept. This concept (which is, ironically, most widely used in the aviation industry) recognizes that human error and faulty systems can cause a mistake, and encourages an investigation of what led to the error instead of an immediate rush to blame a person. Through this process, systems that may perpetrate or perpetuate errors can be fixed. It gives workers the opportunity to feel more at ease reporting problems, and a sense of accountability for system improvement.

While it discourages blame, it is not a “no-fault” system. It does not tolerate malicious or purposefully harmful behavior, and supports disciplinary actions to persons that engage in such behavior. But it supports coaching and education if the mistake was inadvertent, or occurred in a system that was not supportive of safety. Mandatory overtime or insufficient rest breaks on overnight shifts leading to fatigue might be such systems flaws.

The FAA has policies that use of just culture, including its use in preventing fatigue-related incidents. The famous pilot hero Captain Chesley B. “Sully” Sullenberger, in his remarks at a 2010 FAA safety symposium, advocated for the use of just culture in the aviation industry.

“The emphasis on process control and continuous improvement through reporting and learning in a just culture improve quality as well as safety and provide the operator with business benefits,” Sullenberger said. “Just as in health care, quality and safety improve the outcome and the bottom line.”

Sullenberger’s comments point to the uncanny linkages between nursing and aviation. Both feature a high-stress, 24/7 operational environment where there are serious implications on safety if there is an error. Fatigue is a factor – whether it is brought on by the worker themselves (e.g. squeezing in overtime shifts or working a daunting schedule to maximize time off), or the system (e.g. requiring overtime or insufficient staffing). If an error happens, there can be a rush to blame and punish. But a just culture environment can help get the root of the problem, whether it is the worker willfully contributing to the error, or the system providing inadequate support to the worker’s needs. This can help workers feel empowered to solve problems and prevent errors, instead of being afraid.

And in both situations – aviation and nursing – professionalism, advocacy, and policy change can help support safe and efficient environments.

Katie Brewer is a senior policy analyst at ANA.

2 Comments. Leave new

  • Management where I work required a rebid for all positions, the expressed goal was to increase continuity of care with mostly 12 hour shifts. 8 hour shifts weren’t eliminated but decreased. Almost all of us had to change shifts, hours we worked and days off. I had recently changed to 8 hr eves from 8 hr graves for my health but to get the hours I wanted I had to go to 12 hr days. It was not a good transition and now 29 years clinical experience is being questioned in that atmosphere of blame.

  • Nina Stolpe
    June 15, 2011 4:55 pm

    I had the opportunity to attend a research program about “fatique”.
    Result: A person is able to be on top of everything during 6 hours and after 8 hours it declines a lot. This study was done in a European Country.


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