How a "Just Culture" Can Improve Safety in Health Care

Katie Brewer, MSN, RN


Am Nurs Journal. 2011;6(6) 

In This Article

Abstract and Introduction


In April, reports surfaced of air traffic controllers asleep on the job. Frightening audio clips of airline pilots hearing nothing but silence from the control tower went viral, which were quickly followed by calls for immediate firings, resignations from officials at the Federal Aviation Administration (FAA), and plans for congressional hearings. Anger and fear were the day's watchwords.

But the initial uproar and calls for rash action point to a bigger problem for many industries, including health care. As these recent incidents demonstrate, worker fatigue and a "blame culture" are still major impediments to quality and safety.

Fatigue has long been a concern for the National Air Traffic Controllers Association (NATCA). Most of the incidents for the dozing air traffic controllers occurred on overnight shifts, and in some cases, where the night shift controller was on duty alone. In response to the events, NATCA President Paul Rinaldi said in a statement:

"For more than a decade NATCA has expressed its deep concerns about increasing controller fatigue. Our national constitution calls for the ending of single staffing on the midnight shift and for years we have lobbied past Administrations and Congresses on the need to find solutions to controller fatigue before it is too late."

This is a stark parallel to the concerns about nurse fatigue. Working night shifts, rotating schedules, mandatory or voluntary overtime, and long shift hours can take a toll on nurses. And the effects of nurse fatigue on patient and occupational safety are well documented. There have been calls for elimination of 12-hour shifts for nursing based on evidence that they are too long in duration.

Like air traffic controllers, nurses are professionals, and have obligations to avoid working fatigued if they can, and to advocate for workplaces that prevent worker fatigue. ANA has official position statements on nurse fatigue, which address the employer in guarding against fatigue. Nurses are guided by their ethical and professional duties to consider how multiple jobs or voluntary overtime shifts could impact their ability to practice safely. ANA calls on employers to implement workplace policies that help alleviate worker fatigue, thereby ensuring patient and worker safety is not compromised. Other resources for nurses on fatigue are ANA's position statement "Patient Safety: Rights of Registered Nurses When Considering a Patient Assignment, and the Principles for Nurse Staffing.

Nursing is not alone in the healthcare professions in being concerned about working too many hours. Traditionally, medical residents worked very long hours, and even when off-duty, were considered "on call." Most nurses have probably experienced working with a bleary-eyed resident that had been on duty for more than 24 consecutive hours. But through evidence of potential or real harm to patients, an Institute of Medicine report challenged that traditional notion that more was better in terms of hours of education. Subsequently, the medical education accrediting body issued guidelines that restricted the number of hours a resident could be on duty to a maximum of 16 hours per day, and 80 hours per week.


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