A just culture guide


This guide encourages managers to treat staff involved in a patient safety incident in a consistent, constructive and fair way.

The fair treatment of staff supports a culture of fairness, openness and learning in the NHS by making staff feel confident to speak up when things go wrong, rather than fearing blame. 

Supporting staff to be open about mistakes allows valuable lessons to be learnt so the same errors can be prevented from being repeated. In any organisations or teams where a blame culture is still prevalent, this guide will be a powerful tool in promoting cultural change.

About our guide

This guide supports a conversation between managers about whether a staff member involved in a patient safety incident requires specific individual support or intervention to work safely.

  • it asks a series of questions that help clarify whether there truly is something specific about an individual that needs support or management versus whether the issue is wider, in which case singling out the individual is often unfair and counter-productive 
  • it helps reduce the role of unconscious bias when making decisions and will help ensure all individuals are consistently treated equally and fairly no matter what their staff group, profession or background. This has similarities with the approach being taken by a number of NHS trusts to reduce disproportionate disciplinary action against black and minority ethnic staff.

Our guide should not be used routinely. It should only be used when there is already suspicion that a member of staff requires some support or management to work safely, or as part of an individual practitioner performance/case investigation. Remember, you have moved into individual practitioner performance investigation when it is suggested a single individual needs support to work safely (including training, supervision, reflective practice, or disciplinary action), as opposed to where a whole cohort of staff has been identified, which would be examined as part of a safety investigation.

The guide does not replace the need for patient safety investigation and should not be used as a routine or integral part of a patient safety investigation. This is because the aim of those investigations is system learning and improvement. As a result decisions on avoidability, blame, or the management of individual staff are excluded from safety investigations to limit the adverse effect this can have on opportunities for system learning and improvement.

This guide reflects our best current understanding on how to apply the principles of a just culture in practice, in what is a live area of both academic and practical debate. We will revisit and update this guide as new resources become available.  

A just culture guide PDF, 855.5 KB

This guide supports a conversation between managers about whether a staff member involved in a patient safety incident requires specific individual support or intervention to work safely.

Scenarios to support training in using a just culture guide PDF, 230.4 KB

To help with the training, we have developed a series of case scenarios that facilitators can use to walk people through the tool.

This guide updates and replaces the incident decision tree (IDT) developed by the National Patient Safety Agency (NPSA) around the work of James Reason, an expert in human error and its drivers.

A just culture guide helps NHS managers ensure staff involved in a patient safety incident are treated fairly, and supports a culture of openness to maximise opportunities to learn from mistakes.

Our partners

This guide is supported by a number of national healthcare organisations, patient groups and professional bodies including:

  • Academy of Medical Royal Colleges
  • AvMA
  • BMA
  • Care Quality Commission
  • Freedom to Speak Up National Guardian
  • General Medical Council
  • GMB Union
  • NHS England
  • NHS Wales
  • Nursing and Midwifery Council
  • Royal College of Nursing
  • Royal Pharmaceutical Society
  • Unite the Union

"Families would benefit from understanding how the Just culture guide works. Often families call for accountability and think they are asking 'who' is responsible, but my experience is they really want to know 'what happened and why'. This would help them on their journey after the avoidable death of a loved one."

Joanne Hughes, NHS Improvement patient and public representative and founder of mothers instinct 

Insights from NHS trusts with best staff survey results for just culture

To support organisations to achieve a just culture, we sought insights on what should be considered from clinical leaders at trusts across all sectors whose staff say they are treated fairly. Using the 2017 NHS Staff Survey we identified organisations from each sector with the highest percentage of staff that responded positively to the question “My organisation treats staff who are involved in an error, near miss or incident fairly”.

Insights from our 'Just culture in practice' focus group PDF, 176.0 KB

Feedback from organisations on how they are achieving a just culture.

Just culture case profiles

We are curating case examples highlighting approaches specific organisations are following to make their culture fairer and safer. You can view these examples on our Just culture case profiles web page.

What do we mean by ‘just culture’

In June 2018, the Professor Sir Norman Williams’s Review into Gross Negligence Manslaughter in Healthcare report stated ‘A just culture considers wider systemic issues where things go wrong, enabling professionals and those operating the system to learn without fear of retribution’. The report goes on to say ‘‘…generally in a just culture inadvertent human error, freely admitted, is not normally subject to sanction to encourage reporting of safety issues. In a just culture investigators principally attempt to understand why failings occurred and how the system led to sub-optimal behaviours. However a just culture also holds people appropriately to account where there is evidence of gross negligence or deliberate acts’.

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