1. Hader, Richard RN, CNA, CHE, CPHQ, PhD, FAAN

Article Content

My father, a retired U.S. naval chief, taught me several fundamental leadership skills as a young child. He related to me that in order for others to follow your direction, you must become proficient in executing three guiding principles: being fair, firm, and friendly. But he neglected to tell me how difficult it was to balance these standards in a complex environment that often requires immediate and steadfast resolutions.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

As nurse leaders, we're required to critically evaluate difficult situations while simultaneously projecting a consistent approach to solving them. This grows more and more difficult as we conduct root-cause analyses to identify system issues and severe lapses in individual accountability and performance standards of our subordinates.


Creating a workplace that promotes a nonpunitive environment following the exposure of patient safety issues can result in major misunderstandings of intent if an employee is subject to corrective or disciplinary action. Does the promotion of a nonpunitive culture negate a nurse's responsibility and accountability to perform within the scope and standards inherent in her practice? If a nurse's action endangers the safety or life of a patient, is he protected from disciplinary proceedings? How can we clearly decipher if a patient safety event is a system process issue or incompetent and substandard performance?


Bad things happen to good people. As nurse leaders we must clearly and systematically determine if an error is a result of negligence, willful intent, or reckless behavior-or if the system procedures and protocols are precipitating factors in the development of a hazardous situation. Staff and managers need to collectively participate by implementing the processes of root-cause analysis to determine why, when, where, and how the event occurred. Exerting the effort to detail each step in the process will prove beneficial. Recreating the event through discussion and simulation can quickly identify flaws in the process, individual performance, or both.


If you determine that processes need changing, it's essential to get staff input. Carefully consider the development of enhanced policies and procedures to minimize the chance of future error. Your first step? Educate staff members regarding new protocols. If they're not aware of or don't understand the rationale for the change, they most likely won't comply with it. Pilot the newly revised protocol, which will allow for an opportunity to measure success prior to implementation throughout your organization.


Sometimes, individual performance is the culprit of a bad outcome. These instances are troubling and require corrective or disciplinary action. If you determine that the nurse acted in a manner inconsistent with prudent practice, initiate remediation immediately. Counsel the nurse regarding your findings and offer suggestions and feedback to improve his or her performance and opportunity to succeed in the future.


Mistakes will happen, and staff should realize that discipline might be a result following careful examination of all the facts. Substitute the term "nonpunitive" with "just culture," meaning that each incident will be vigilantly reviewed to determine appropriate actions and next steps. A culture of shared responsibility between staff and your organization will help to promote collaboration and rapid implementation of corrective actions, minimizing the chance of error. Just culture can and will enhance patient safety, as well as foster a culture of mutual accountability between nurse and healthcare facilities.