Assessment of the Perceived Just Culture Among Nurses: A Cross-Sectional Study

Background Achieving a highly reliable system and processes in the healthcare industry is a classic conundrum. As safe and quality healthcare has its increasing complexity, where errors are more likely to occur. Hence, most healthcare organizations have promoted the practice of Just Culture. The research study quantied and explained key aspects on the strengths and weaknesses of just culture dimensions which facilitated understanding in implementing a safety culture in Hamad General Hospital (HGH). Design: Perception was measured using the adapted JCAT through a descriptive, cross- sectional research design. Independent T-tests and One-way ANOVA were used to investigate the relationship between the demographic prole and just culture perception among 212 staff nurses in HGH. Results A strong positive perception among the staff nurses of Just Culture was found out based on its six (6) dimensions in Medical and Surgical In-Patient Units of HGH. Positive response rate is highest at Continuous Improvement dimension which is 88.66%. Balance dimension received the lowest rating with only 52.31% positive response rate. The research study utilized a simple random sampling technique. The research study examined the perception of Just Culture from 212 staff nurses’ perspective, as staff nurses were more proximate to patients and more directly involved in patient care (like those most likely to affect patient safety). The total response rate was 86%, which means that there were 257 returned responses from 300 sent out surveys. 45 responses were eliminated after it was identied as an incomplete data like failure to give consent, missing responses and skipped some question items.


Introduction
Achieving a highly reliable system and processes in the healthcare industry is a classic conundrum. As safe and quality healthcare has its increasing complexity and signi cantly in uenced by healthcare provider's performance behavior vis-a-vis with high patient acuity and cerebrally dependent processes, were errors are more likely to occur. Since clinicians are more prone to errors or perhaps make errors, [4] most healthcare organizations have promoted the practice of Just Culture, but its impact has never been assessed. [1] The framework of a just culture ensures balanced accountability for both individuals and the organization responsible for designing and improving systems in the workplace. [3] Gaps in existing researches on just culture were identi ed in that: 1) not many studies about just culture have been conducted; 2) insu cient research has been performed to investigate how demographic factors were critical to affect the just culture perception among nurses; and 3) there have been limited studies conducted in exploring the composite measures of just culture against the demographic pro le of the nurses especially in the Middle East.
Hamad General Hospital (HGH) is the largest institution in the State of Qatar which envision to be an internationally-recognized global provider of healthcare excellence while offering various multidisciplinary services. To achieve a strong and stable patient safety culture, it is rst necessary to accurately assess the status quo in order to reshape or optimized safety practices that would leverage in accreditation processes like the Joint Commission International (JCI) and soon the Magnet program.
Just culture operates as a subset of safety culture, meaning that certain aspects of overall patient safety culture are less relevant. The existing patient safety culture instruments lack the ability to directly gauge the concepts important to just culture like perceptions of fairness and trust in the way management and an organization react to adverse safety events. [8] The medical and surgical in-patient units of HGH have been one of the areas identi ed to have an increasing number of errors and sentinel events where 91.5% of medication errors were classi ed as active failures and indeed, the most reported event. [14] The research study assessed the individual perceptions in the nursing workforce of HGH through utilizing the Just Culture Assessment Tool (JCAT) and investigated the signi cant relationship between the perception of nurses to just culture and their demographic pro le. The study also quanti ed and explained key aspects on the strengths and weaknesses of just culture dimensions which facilitated understanding in implementing a safety culture.

Background Of The Study
Hospitals are imperfect systems where nurses have competing demands and are forced to improvise and develop workarounds. [7] Clinical nurses, however, can have a signi cant impact on reducing errors due to their proximity to patients. Just Culture is a safe haven that supports voluntary reporting; that organizations are accountable for systems they design and analysis of the incident not the individual, and describes a work environment in which individuals believe they will receive fair and just treatment when involved in an adverse event. [8] Many publications on patient safety existed but the organizational climate and just culture reports within Qatar has not been studied. [9] According to the database report of the Agency for Healthcare Research and Quality (AHRQ) [2,13] , the area with the lowest percentage of positive responses was the "non-punitive response to error [or Just Culture], while the highest area of strength for a healthcare organization was "teamwork within the unit". Interestingly, a research study conducted locally on the assessment of perceived safety culture of nurses in Hamad Medical Corporation (HMC), [1] which results showed that frequency of events reporting was as low as 44% (in average); near-miss reporting which is only 28%; and actual error reporting was only 34%. While, the overall positive response rate for the study on the non-punitive response to error dimension was only 23%. Speci cally, 76% of the staff nurses feel like their mistakes are held against them and 66% of them feels like an individual is being incriminated when an incident report is led. [1] These result ndings suggested a further investigation in assessing the practice of just culture and emphasized identi cation of causes of the low positive response rates. It also allows the measurement and interpretation of different dimensions of just culture, and subsequently, how nurses excel or struggle with each dimension as it has contributed to the low response rates in safety culture surveys in Qatar.
Nevertheless, the concept of measuring the perception of Just Culture helped develop strategies in aligning hospital goals and develop policies in advocating support for the second-victim clinicians specially nurses. This study was a rst step toward introducing the concept and measurement of Just Culture in Hamad Medical Corporation (HMC) and perhaps any healthcare organizations in the Middle East. As compared in assessing the safety culture in general which is usually done by most organizations, Just Culture assessment is a practical and novel way to investigate how an organization like HGH fosters a just and safe system in response to error.

Research Questions
The research study answered the following research questions:

Scope And Limitations Of The Study
The scope of the research study focuses on quantitative examination in assessing the level of perception of Just Culture among staff nurses in medical and surgical in-patient departments of HGH while utilizing the adapted and rephrased survey instrument called the Just Culture Assessment Tool (JCAT). Assessment of the just culture will be gauged based on its six dimensions which includes feedback and communication, openness of communication, balance (composed of both non-punitive treatment as well as accountability), quality of the event reporting process, continuous improvement and trust. The duration of the research study was 2-3 months.
However, the limitations will be con ned in assessing the level of perception of just culture dimensions through answering an adapted version of survey questionnaire. The results will not be generalizable to all areas of nursing and to the nurses of the whole state of Qatar. The ndings of the research study, nonetheless, could be subjected to other interpretations using the parametric statistical tests like independent t-test and One-way Analysis of Variance (ANOVA).

Research Methodology
A descriptive, cross-sectional research design was used to gather data among the nurses across HGH.

Participants Of The Study
The research study utilized a simple random sampling technique. The research study examined the perception of Just Culture from 212 staff nurses' perspective, as staff nurses were more proximate to patients and more directly involved in patient care (like those most likely to affect patient safety). The total response rate was 86%, which means that there were 257 returned responses from 300 sent out surveys. 45 responses were eliminated after it was identi ed as an incomplete data like failure to give consent, missing responses and skipped some question items.

Ethical Consideration
The research was granted an "IRB Exempt Review" from the Hamad Medical Corporation (HMC)-Medical Research Center (MRC) with MRC Protocol No. MR-01-20-962.

Instrumentation
For this research study, the Just Culture Assessment Tool (JCAT) was adapted and utilized. [8] The JCAT consisted of 27 questions and had six dimensions which included 1.) Feedback and Communication (3 items); 2.) Openness of Communication (5 items); 3.) Balance (5 items); 4.) Quality of Event Reporting Process (5 items); 5.) Continuous Improvement (4 items); and 6.) Trust (5 items). [8] The questionnaire made sure that the terms were aligned with the terms used by the HGH nurses like the use of OVA or occurrences, variances, and accidents as a term for the means of reporting. Also, some terms were modi ed for easy understanding to the questions. The survey consisted of three parts: 1.) consent form, 2.) the nurses' demographic pro le and the 3.) survey questions on Just Culture with a 7-point Likert scale (Strongly Agree = 1 to Strongly Disagree = 7). It was administered online through a Q survey program in an English version and took for 10-15 minutes to complete.

Data Analysis
Data from the Q-survey platform were exported, Microsoft Excel was used to clean and prepare the data and for the analysis proper, SAS Studio was used to analyze the data. The data were analyzed using descriptive and inferential statistics, including frequency and percentage; and parametric statistical tests at 0.05 alpha signi cance level by a biostatistician For demographic pro le, descriptive statistics such as frequencies and percentages were used to summarize the demographic pro le of the surveyed nurses.
To assess the perception of the nurse's towards Just Culture, the number of positive responses (strongly agree, agree, and somewhat agree) and positive response rate were calculated for positively worded items as well as for reversely worded items (Items were A2, B1, C1, C2, D1, and F5), where disagreement indicated a positive response (strongly disagree, disagree, and somewhat disagree), for each dimension. Additionally, a dimension-level response rate was calculated by getting the total number of responses in the respective consolidated levels of agreement (agree, neutral, disagree) and dividing it by the product of overall total number of surveyed nurses and total number of items in the dimension.
To test the relationships between demographic pro le and just culture perception, respondent-level mean scores for each dimension was computed prior to hypotheses testing and then compared across pro le categories. The mean scores for each respondent were derived by getting the sum of the corresponding numerical value of the levels of agreement (1-Strongly Agree, 2-Agree, 3-Somewhat Agree, 4-Neither 5-Somewhat Disagree, 6-Disagree, 7-Strongly Disagree) for all statements and dividing the sum by the total number of items in that speci c dimension. Hence, a respondent will have six mean scores representing the six dimensions -Feedback and Communication, Openness of Communication, Balance, Quality of Events Reporting Process, Continuous Improvement, and Trust.
In this study, independent sample t-tests were utilized to test the signi cant differences in the mean scores across gender, and nationality, for each just culture dimension. While comparisons between culture dimension scores across age groups, area of work, and years of experience (in HGH) utilized one-way ANOVA. A post-hoc analysis was performed to a signi cant global test to pinpoint where speci c differences were observed.

Results
Demographic Pro le A total of 212 valid survey respondents were gathered from the data collection. Their demographic pro les are summarized in Table 1 below.

Just Culture Perception
The consolidated response rates for each dimension are summarized to describe the general perception of the surveyed nurses towards Just Culture in Table 2 below. From the same table, it can also be observed that despite having high positive response rates, negative response rates are consistently higher than the neutral scores. The consolidated response rates for item-level of the questionnaire are available in Appendix.

Correlation of Demographic Factors and Just Culture Dimensions
Further details on dimension scores across pro les will be presented to determine the relationship between the demographic pro le and the perception of the surveyed nurses to Just Culture dimensions. The results of their respective two-sample t-tests and one-way ANOVAs are summarized in the succeeding tables.  Table 3, the results of separate one-way ANOVAs on mean dimension scores across age groups did not yield anything signi cant since all p-values are greater than the set level of signi cance (α = 0.05). Therefore, for each dimension, the mean scores across age groups are not signi cantly different from each other.
It was concluded that older workers are more safety conscious than younger workers. [6] It may be assumed that older workers are more con dent and experienced in their work leading to fewer accidents. Their studies of safety perceptions con rm that younger workers have a less positive attitude toward safety than older workers. But contrary, to the results of this research study, found no signi cant relationship between the two variables. Age might be an important demographic factor but quality of experience which would affect the perception aspect on certain things doesn't come with years of living but with years of experience.
Hence, the null hypothesis of there is no signi cant relationship between age and perception of just culture among nurses was accepted. Perhaps the most widely demonstrated demographic factor related to risk perception is that of gender. [12] Regarding demographic determinants of risk perception, a consistent pattern in the literature is that women tend to perceive risks to be larger than men do. [12] Based on the results of this research study the perception to risk is not the same as how an individual perceived safety. The perception to risks focuses on the threats and factors that could make the system go wrong while perceived safety is when how an individual makes things right to safe workplace. This is clearly a paradigm shift of Safety-I to Safety-II ideologies on how individuals think to certain aspects between risk, errors and safety which also justi ed the results of this study. However, safety interventions need to consider risk perception and reduce the level of risk people are willing to tolerate.
Having no signi cant relationship between the gender and the just culture perceptions, on contrary from the results of different researches, risk perception is a critical antecedent to at-risk behavior. to the Filipino respondents. Cross-cultural differences are based on average group values, they re ect only a general tendency in a culture, which does not have to be true for every individual but nevertheless gives a useful indication of the behaviors that can be expected. [10] Filipino groups in the research have lesser scores to positive response to just culture than the non-Filipino groups because the Philippines has a higher power distance index than other countries together with Taiwan and Morocco. [10] Power distance index (PDI) is the extent to which the less powerful members of organizations and institutions accept and expect that power is distributed unequally. For instance, safety perceptions may be compromised if subordinates are unwilling to challenge leaders' actions or decisions. And so, national culture with a high PDI would tend to accept (safety) instructions from their supervisors more easily which explains the signi cant difference between just culture perceptions and nationality.
Relationships among cultural values, management commitment to safety (safety climate) and risk-taking behavior appear not to be uniform across cultures but is a signi cant predictor. More importantly, the study highlights that the commitment of corporate (senior) managers is a more important determinant of workplace behavior than national culture. These culturally rooted differences have, in some cases, been able to explain certain variations in safety behavior and performance across work teams, within and/or between organizations. As such, national culture related to nationality groups is one of the best predictors of attitudes, behaviors, and performance in the workplace especially on the context of safety. [10] Furthermore, cross-cultural differences re ect only a general tendency in a culture, which does not have to be true for every individual but nevertheless gives a useful indication of the behaviors that can be expected. [10] The diversity created by mixed nationals with mixed cultures adds value to the organization by utilizing the skills and experiences that employees have developed as members of various cultural identity groups. [10] Cultural background in uences how an individual perceives another context of culture which is safety. Results of the research study explained about the "culture on culture" factor, where an individual's culture by nationality gives a signi cant difference on how the organizational just culture is being perceived and practiced. Cross-cultural differences polarized the practice, the behavior, the perception, and the way of thinking of the group of people. Different nationalities project its own set of practices and interpretations on such causing a varied perception. Accordingly, the common ground to alleviate the differences on the so-called "culture on culture" factor is organizational leadership.
Hence, the null hypothesis of there is no signi cant relationship across nationality and perception of just culture among nurses was rejected. To determine the effect of area of work to the perception of the surveyed nurses towards Just Culture, results of one-way ANOVAs are presented in Table 6. From the table, each of the following can be concluded at 0.05 level of signi cance: 1. At least one area of work yields a signi cantly different mean Feedback and Communication dimension score. 2. At least one area of work yields a signi cantly different mean Openness of Communication dimension score.
3. At least one area of work yields a signi cantly different mean Balance dimension score. 4. At least one area of work yields a signi cantly different mean Quality of Events Reporting Process dimension score.
While area of work assignment can signi cantly affect just culture perception. Each area of assignment has a different structure of leadership & hierarchy that brought varied differences of leadership and management styles. Although there is a system design, gaps in the implementation brought by different styles of leading and managing in each area might cause varied perception under the context of safe and just practice.
From all the post-hoc analyses, it is evident that Acute Medical Assessment Units (AMAUs) has consistently yielded the highest mean dimension score.
However, variances in the understanding of just culture suggest that leaders and managers should play a role for high-impact leadership.
To create and sustain a strong just culture, it requires a leader to be mindful of the differences on its subordinates' demographic pro le which caused diversity. It could be inferred that leadership is a more important determinant of safety behavior than national culture.
While age, gender, and length of experience, although were unique factors, posed no signi cant differences to the perception of safety.
Therefore, the null hypothesis of there is no signi cant relationship between area of work and perception of just culture among nurses was rejected.  Table 7, none of the one-way ANOVAs on the Just Culture dimension scores across years of experience (in HGH) returned a signi cant result since none of them met the criterion of having a p-value less than the level of signi cance (α = 0.05). Hence, years of experience, like the previous results using gender and age group, does not in uence the perception of the surveyed nurses towards Just Culture and thus, null hypothesis of having no signi cant relationship between years of experience and perception of just culture among nurses was accepted.
There is no contextual effect of length of hospital experience to safety perceptions, [15] although this seems reasonable given research showing no link between aggregate experience and patient outcomes, [15] one limitation may be the one-dimensional measure of experience as a number of years. Benner (1984) noted that experience depends not only on the passage of time but also on the availability of actual situations through which a nurse can re ne, elaborate, or discon rm knowledge which later on could affect their decision-making, perception and evaluation on certain aspects. [15] Results also suggested that individuals have its own responsibility in learning the salient points in the practice of just culture. Whether your young or a senior in your professional experience, it is the individual's duty to grow and expand professionally in the practice. Similarly, a limitation of this research study that is also common throughout the literature is the use of a measure of experience based solely on time. [15] SUMMARY OF FINDINGS

Conclusion
This research study reports on ndings from an analysis of just culture perception among nurse and its demographic pro le characteristics. Implications on this research study contributed to the practice of strong and positive just culture on which perceptions varied on speci c demographics among nurses. Demographics like area of work and nationality have been critical to affect the perception of just culture among clinicians specially nurses based on the speci c just culture dimensions. Results of the research study explained about the "culture on culture" factor, where an individual's culture by nationality gives a signi cant difference on how the organizational just culture is being perceived and practiced. Accordingly, the common ground to alleviate the differences on the so-called "culture on culture" factor is in uenced by organizational leadership.
Moreover, the ndings of this research study showed positive perception of just culture in contrast with the previous local researches of safety culture in Qatar from 2008 where non-punitive approach to errors resulted to a low perception response rate.
Reasons for this improvement includes different programs, campaigns and processes implemented which involved in raising awareness and knowledge on how to practice safe and just culture across HMC facilities. Leverage to external organizations like JCI, Institute of Healthcare Improvement (IHI) and so on might contributed the improvement of nurses' perception to what is meant to have a just culture. Streamlined quality improvement processes, like from the Hamad Healthcare Quality Institute (HHQI) can also be a contributing factor in the highest positive perception rate of continuous improvement by initiating collaborative projects and value improvement programs in the facility.
The positive practice of just culture in the facility has galvanized its rst steps in building concepts and framework in achieving to be a high reliability organization. Balance composed of both non-punitive treatment as well as accountability remained an area to be improved and developed. Consequently, assessing the just culture perception among the clinicians would give as a bigger picture on how safety perception variances would help in improving the practice. Also, just culture assessment is a different approach to create opportunities on how to achieve and sustain improvements. Equally important, how trusts and accountability towards the leadership and management creates to a strong perception to just culture.

RECOMMENDATIONS:
The results of this research study yielded to the following practical recommendations in order develop a strong just culture practice: