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

This explored the barriers and enhancers to trust in error reporting in a just culture. They systematically evaluated healthcare research, with just 14 studies meeting inclusion criteria.

Providing background, they note:

·????????Trust in a just culture, in their methodology, was defined as when "professionals believe that error communication is honest, safe, and reliable”

·????????A very brief history of the just culture concept was covered. It was said to have been predated by a blame-free safety culture, where people could report without risk or punishment. However, a downside to this approach was apparently the lack of consequences for deliberate acts of damage or gross negligence, leading to a sense of injustice

·????????A just culture was said to have evolved to fill in the limitations of a blame-free approach [and restorative approaches arguably to cover limitations in just culture approaches]

·????????Creating just cultures isn’t simple and one reason are legal considerations. E.g. “One could say that law primarily looks backward to establish liability, whereas just culture primarily looks forward to establishing future safety” (p1067); creating difficulties in responding to intention because just cultures only punish in cases of gross negligence or wilful misconduct in contrast to legal responses

·????????Another challenge for just culture approaches is a tendency to “sharply distinguish between acceptable and unacceptable behavior. While most scholars consider this to be a hallmark of a just culture, some, such as Dekker and Breaky,3 opine that this is not possible and that emphasis should be put on a restorative approach in which the needs of all stakeholders are addressed” (p1067)

·????????Trust is essential to successfully instigating a just culture but trust isn’t often defined in definitions of just culture, which is problematic for the study of the concept.

Results

Key findings included:

·????????They found 3 main barriers and enhancers to trust in error reporting cultures: organisational factors, team factors and experience.

·????????They found that “trust can be learned and created based on practical principles” (p1073).

·????????First, trust in error reporting is influenced by experience and training in patient safety. Lack of confidence in clinical skills, fear of shame/blame and knowledge of the existing error reporting system influence the success of a just culture system.

·????????Organisations influence team factors. A close relationship between employee and supervisor and discussion of the nature of error and clear definitions of the role of physicians can increase trust in error reporting.

·????????Creating mutual understanding of the challenges faced by professionals can enhance trust.

·????????Third, organisational factors play an important role in promoting trust in the communication of errors. Trust depends on managers being supportive and committed to reporting and focused on improving conditions rather than on blame.

·????????Conversational walkarounds and on establishing and promoting professional practice are effective, as is a departmental incident reporting system (as opposed to an organisational reporting system).

I’ll cover some of these now in more detail.

Organisational factors

For organisational factors, as expected trust pivoted on management support. Leadership commitment enhanced the culture of safety via stimulating trust.

Further, openness on the part of senior or more experienced operators (in this case, physicians or medical directors) about errors and incidents enhanced trust among staff.

Uncertainty about how reports of incidents and the like would be handled worked as a barrier to trust. Conversational walkarounds where leaders would discuss issues of safety and work with frontline staff with a view to creating improved conditions, fostered higher trust.

In contrast, surveillance-orientated walkarounds, where executives check up on frontline staff, created distrust.

The implementation of a multidisciplinary code of professionalism for all staff irrespective of position, was found to improve conditions because “indifference to unprofessional behavior between disciplines creates an atmosphere of distrust and compromises patient safety” (p1068).

They found that departmental incident reporting systems—which are run by healthcare professionals rather than managers—promoted more trust and confidence in the reporting system compared to an organisational-level reporting system. In contrast, “a hospital-wide incident reporting system was found to create distrust” (p1072).

[** This has been observed in construction also, where project/operations/departmental incident systems are found to enhance reporting, trust and other indices compared to the usual organisational reporting systems.]

Team Factors

Fostering close professional relationships between managers and staff was found to be more effective in creating trust than “a more distant organizational culture” (p1072, emphasis added).

Clearly defining the roles of professionals in a team made it easier for people to ask questions about safety.

Experience

Experience also played a role. One study found that over 56% of experienced trainees reported errors compared to 43% of beginner trainees; more experienced trainees compared to beginners believed whistleblowing to be vital for protecting patient safety.

More experienced operators were more willing to admit and talk about error in another study, with less experienced operators tending to be less open. In another study, first year residents experienced more barriers to speaking up compared to third and fourth year residents.

Two important barriers were the lack of knowledge on how to speak up and the lack of confidence in skills.

Frontline staff are often afraid to report errors and performance issues, such as: 12% feeling shame or 33% fearing blame. In contrast, only ~20% of supervisors or senior managers fear blame from errors.

In discussing the findings, they note a key finding is the negative effect of hospital-wide reporting systems around trust. Organisational level reporting systems, common in most organisations, “was considered “faceless” and created distrust” and part of this related to the uncertainty about how the reports would be handled or acted upon.

Departmental reporting systems run by peers and not managers were seen as more trustworthy, and seen to more directly interface with medical procedures and practice.

Good manager-staff relationships is critical, and enhances communication and trust. Surveillance approaches generate distrust in error communication; leading to people hiding mistakes.

In contrast, conversational approaches foster closer relationships.

Interprofessional meetings can bring issues about distrust into the open and thereby stimulate trust.

Skills on how to speak up were found to be essential, as was the willingness of more experienced colleagues to discuss their own errors. The latter was found to help people lower in the hierarchy feel less shame or worry about speaking up.

The authors note some limitations of the study and challenges in studying trust and just cultures more generally:

• First, they found “relatively little research into trust about error reporting in a just culture” (p1073).
• Second, much of the existing research was cross-sectional, which made it difficult to measure the effects of interventions on outcomes.
• Third, “Trust is a concept that can only be measured qualitatively, not quantitatively” (p1073).
• Fourth, there’s blurriness around whether a “safety culture could be regarded as a just culture”, with a high degree of subjectivity involved in the assessment.

Link in comments.

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