Promote a just culture

We believe a ‘just culture’ is one that balances fairness, learning and accountability. There are different ways to embed a just culture. They’ll help make sure that all of the contributing factors in a person’s actions, inactions or behaviours are considered.

Using tools and processes that promote a just culture will help you look at concerns in a way that avoids fear and blame. It will also help professionals and people who use services to feel confident about speaking up, knowing they’ll be supported and treated fairly.

For example, the approach as outlined in NHS England’s A Just Culture Guide can be used as soon as concerns arise or when a patient safety incident suggests that there may be concerns about someone’s practice. The just culture guide uses a series of questions to help you understand whether someone’s practice may be putting people who use services at risk.

With this approach, you’ll be able to take into account any relevant contextual factors that may need to be addressed separately from concerns about a professional. For example, contextual factors may include:

• staffing levels, skill mix and workload at the time of the incident
• a constantly changing environment presenting new challenges
• unusual expectations for staffing levels and workload pressures
• distractions
• management pressure or poor management
• physical environment
• device, equipment or product design
• working practices, social norms or organisational/team culture
• history of bullying, harassment or discrimination in the team
• personal stress, health problems.

This approach can help you understand whether someone else with similar experience and qualifications would have acted in the same way or made the same decisions in the same circumstances. If they would, there are likely to be wider issues that need to be addressed.

A just culture approach also will help you decide the best course of action for people using services and for the professional involved.

If you do make a referral to us, we’ll ask you for documentation showing any contextual factors that you found to be relevant to the concerns, such as those listed above.