1. Battard, Juliet DHSc, RN

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Given the criticality of improving patient safety in healthcare, the goal of establishing and nurturing a just culture, including nonpunitive response to errors, grows increasingly predominate among engaged nurse leaders. Nonpunitive response to errors is a primary dimension of a hospital's patient safety culture that we can measure through staff surveys. This article describes a successful hospital nursing staff initiative that resulted in an improved nonpunitive environment as measured by responses on the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture.1

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Skip the blame game

Effective response to errors requires clear communication that the primary goal of error investigation is to identify system issues rather than criticize individuals.2 Blaming individual nurses for errors detracts from the patient safety goal of identifying systems in need of improvement. Implementing a just culture-one without inappropriate punishment for individual errors-promotes valuable comprehensive incident reporting and avoids nurse hostility and resentment.3 Approaching nursing errors from a nonpunitive perspective also influences nurses to be motivated to engage in safe behaviors in their daily practice.4


Nurse leader responsibilities

Managing patient safety culture change requires nurse leaders to serve as change agents, demonstrate openness to change, and reward creative and innovative thinking.5 Fostering teamwork and open communication while minimizing organizational hierarchy is fundamental to developing and nurturing a just culture.2 Nurse leaders who evaluate staff performance using nonpunitive and impartial standards experience transparency in error reporting.3


The American Organization of Nurse Executives has established the following competencies required for nurse leaders to serve as patient safety culture change agents:


* Support a nonpunitive reporting environment and a reward system for reporting unsafe practices.


* Support safety surveys by responding and acting on safety recommendations.5



Measuring staff perceptions

The AHRQ Hospital Survey on Patient Safety Culture groups questions into the safety culture dimensions they're intended to measure.1 The questions that comprise the nonpunitive response to errors dimension are negatively worded, so "strongly disagree" and "disagree" are the desired responses. The survey statements for staff response are:


* Staff members feel like their mistakes are held against them.


* When an event is reported, it feels like the person is being written up, not the problem.


* Staff members worry that mistakes they make are kept in their personnel file.1



Training is key

Intervention, such as training, can improve nurse perceptions of safety culture.4 Nonpunitive environment implementation training can help establish a strong, protective infrastructure in which nurses feel safe when engaging in responsible, accurate reporting of patient safety concerns. Nurse training is a key component of building a successful program that ultimately improves healthcare safety by eliminating nurses' fears of retaliation for accurate and trustworthy error reporting.2


Upon identifying an opportunity for improving nonpunitive response to errors, Nancy Hilton, the CNO at St. Lucie Medical Center in Port St. Lucie, Fla., implemented training to empower frontline unit-based nurse leaders to make the needed patient safety culture change. The hospital had an existing nursing shared governance council structure that provided an expedient structure for initiating the process improvement and communicating nonpunitive response to errors as a patient safety priority.6 Council participants and training recipients included members of the following nurse councils: nursing leadership, nursing quality, nursing professional development, nursing research and evidence-based practice, nursing professional practice, and clinical nurse leaders.


Through their participation in shared governance councils, approximately 60 nurses received the training. In addition to unit-based nurse managers and clinical nurse leaders, council memberships included a large number of patient care coordinators, or charge nurses. By providing these frontline leaders with real-world examples of how to effectively respond to errors, the tools for implementing the training were given to the individuals who could most credibly and convincingly communicate the change. Responding to nurse errors is part of the routine work of unit-based leaders and the members of the nurse quality council who engage in peer review. These individuals were positioned to effectually demonstrate to staff members that mistakes wouldn't be held against them.


The training included information about the futility of a blame culture and the rationale for and value of nurses perceiving that they work in a nonpunitive environment. Additionally, the training provided concrete examples of responding nonpunitively to errors, including the examples listed in Table 1.

Table 1: Examples of... - Click to enlarge in new windowTable 1: Examples of nonpunitive responses to errors

To follow-up on the training, nurse directors provided real-time coaching on appropriate responses when errors occurred. Hospital executive leaders also reinforced their support for nonpunitive response to errors as part of a strong culture of safety and led by example.



The results of the training, as measured by the hospital's nursing staff survey responses before and after the intervention, are shown in Figure 1. The three statements that contributed to the overall nonpunitive response to errors domain are abbreviated. The percent of desired response reflects the percentage of nurses who disagreed or strongly disagreed with each of the three statements.

Figure 1:. Nurse per... - Click to enlarge in new windowFigure 1:. Nurse perceptions before and after intervention

The results demonstrated a meaningful improvement in nurse perceptions of each statement and the nonpunitive domain, overall. No other patient safety domain experienced a similar dramatic improvement in the 2016 survey results, as compared with the 2014 results.


Improving safety culture

Frontline nurse leaders are well situated to implement safety culture process improvements contributing to the truthful and reliable reporting of errors. Armed with knowledge of the benefits of nonpunitive response to errors and tangible actions to create a nonpunitive environment, we can cultivate a strong and just safety culture. The provision of education and training to frontline unit-based nurse leaders through established nursing councils in a shared governance structure can contribute significantly to the achievement of an improved safety culture. The result is nurse leaders who possess the ability to effectively demonstrate nonpunitive response to errors and are equipped to successfully improve the patient safety culture in their individual nursing units.




1. Agency for Healthcare Research and Quality. Hospital survey on patient safety culture. [Context Link]


2. National Association for Healthcare Quality. Call to action: safeguarding the integrity of healthcare quality and safety systems. [Context Link]


3. Harrington LC, Smith M. Nursing Peer Review: A Practical, Nonpunitive Approach to Case Review. 2nd ed. Danvers, MA: HCPro; 2015. [Context Link]


4. Weaver SJ, Lubomksi LH, Wilson RF, Pfoh ER, Martinez KA, Dy SM. Promoting a culture of safety as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):369-374. [Context Link]


5. American Organization of Nurse Executives. AONE nurse executive competencies. [Context Link]


6. St. Lucie Medical Center Nursing Annual Report. Nurses driving innovation. 2011. [Context Link]