Just Culture

Sep. 26, 2016 · 10 min read

A just culture is a culture of trust, learning and accountability.

It is important to have when something goes wrong in your organization. There are basically two ways:

A retributive just culture asks:

Which rule is broken?
Who did it?
How bad was the breach, and what should the consequences be?
Who gets to decide this?

A restorative just culture asks:

Who is hurt?
What do they need?
Whose obligation is it to meet that need?
How do you involve the community in this conversation?

Sidney is one of the key thinkers behind Just Culture. He has surprising and inspiring ideas that you might not find elsewhere. Here you can learn about problems with a Retributive Just Culture (the approach taken by many organizations today), and the possibilities for a Restorative Just Culture—also in your organization. Look at this short film to learn about the difference.

“Just Culture” is a way for organizations to justly respond to mistakes and violations. Many organizations think that Just Culture is about dividing people’s actions into shades of culpability:

Honest mistake, you can stay.
Risk-taking, you get a warning.
Negligence, you are let go.

These organizations have mixed results with a retributive ‘just culture,’ because:

Who draws the line between these shades of culpability, and is she or he independent?
Does he or she know the nuances and messy details of the practitioner’s work?
Is there a right of appeal?
There is no evidence that these organizations learn more of value after an incident.
The more powerful people typically consider their organization’s culture to be more ‘just.’

Can you get retribution right?

Retributive justice is about rules, violations and sanctions. It believes that wrongdoing creates guilt and that it demands something from the offender to compensate it. Here is how retribution tries to create justice, prevention and learning:

It asks who is responsible for the incident and focuses on what they deserve
It looks back on the wrongdoing and imposes consequences for it
It has the offender settle his or her account to pay off the guilt
To do so it imposes a proportional and deserved sanction
It learns and prevents by setting an example
It builds trust by reinforcing rules, advertising them and giving people authority over them
It meets hurt with more hurt

This is the idea. It may not always work, for example in your organization. When retributive justice is imposed, make sure you check this:

Is the ‘judge,’ the one who draws the line on the practitioner’s behavior, independent? A ‘judge’ (say, a nurse manager in case of a medication adverse event) who has a stake in the outcome is not independent.
Does the ‘judge’ or ‘jury’ know enough about the messy details of practice to know about the many unwritten rules, standards and expectations about how work actually gets done?
Is there an opportunity for appeal? Natural justice allows people a chance to be heard again by an unbiased party. Does that happen in your organization?
Does retributive justice in your organization promote honesty, openness, learning and prevention?

A restorative just culture meets hurt with healing, welcomes multiple stories about the event, and focuses on restoring relationships and trust.

In retribution, an account is something you pay.
You repay the debt you morally owe; you settle your account with your organization, victims, community, society by receiving a proportional and deserved punishment.
It asks who was responsible, and sets an example.
In restoration, an account is something you tell.
You, like others involved, give an account of how the event happened and what it meant to you.
Together, you determine how to meet the needs that have arisen from the event.
It asks what is responsible, and then changes what led up to the incident.

Restorative justice is about hurts, needs and obligations. It believes that harms create needs, and that needs create obligations. The entire community is involved in resolving whose needs need meeting, and by whom. It isn’t just focused on the offender. In fact, the so-called ‘offender’ may well be a victim him- or herself: a second victim. Here is how restoration tries to create justice, prevention and learning:

It asks who is hurt and what their needs are
It looks forward by assessing who can, or should, meet those needs
It invites all affected to tell their accounts of the harm and their needs
To do so it invests in relationships and repairs trust
It learns and prevents by asking why it made sense for people to do what they did
It builds trust by repairing relationships between people whose work depends on each other
It meets hurt with healing

Neither retributive nor restorative justice let people ‘off the hook’

Both retribution and restoration acknowledge that a ‘balance’ has been thrown off by the incident and its consequences. Both acknowledge reciprocity, an ‘evening of the score.’ But they differ on the ‘currency’ to rebalance the situation. Both impose accountability. But they go about it in different ways:

Retributive justice achieves accountability by looking back on the harm done. The community can demonstrate that it does not accept what the person did (it would not accept such actions from any of its members), and demonstrates that it makes the person pay.
Restorative justice achieves accountability by looking ahead to meet the needs and repair the trust and relationships that were harmed. It wants to understand why it made sense for the person to do what they did. For this, they an account, a story. People are accountable by reflecting on their actions and understanding what was responsible for producing it. This also gives them the opportunity to express remorse. The community decides whose obligation it is to meet the needs that arose from the incident, and agrees how to do this.

Neither form of just culture gets ‘people off the hook.’ Both hold people accountable. In both, people are expected to engage with, and respond to, the community of which they are part.

Restorative justice as we know it today began in response to relatively minor crimes—often property crimes, such as burglary in the 1970’s. But its roots can be traced much further back: hunderds and even thousands of years. The ancient Sumerians, Babylonians, Hebrews, Romans and Gauls—to name a few—all applied forms of restorative justice. They organized restitution for property crimes, relying on input from victims and offenders. First Nations in North America, New Zealand and elsewhere have long had values and practices of restorative justice. Encouraged by the results and its humane approach, restorative justice has recently been promoted for juvenile offenses. It has spread to schools, workplaces and religious organizations. Children often spontaneously apply restorative justice. Restorative justice has been applied successfully on a massive scale by the Truth and Reconciliation Commission in post-Apartheid South Africa. John Braithwaite defines restorative justice as:

…a process where all stakeholders affected by an injustice have an opportunity to discuss how they have been affected by the injustice and to decide what should be done to repair the harm.

You can’t really buy a just culture from a consultant. Because it won’t be a culture, and it probably won’t be just. A just culture can only be built from within your organization. Just culture need to be tried, bargained and decided among your own people.

Of course, people from the outside can help: with ideas, suggestions, a language or even some principles. Have a look at the restorative principles here, for example. And learn which processes and people are typically involved.

An incident in your organization can hurt various people:

First victims: patients, passengers, colleagues, surrounding community who suffer consequences.
Second victims: the practitioner(s) involved who feel(s) personally responsible and suffer(s) as a result. Your practitioners are not necessarily the cause of the incident. They themselves are the recipients of trouble deeper inside your organization.

First victims typically need information about the incident. What happened, and why? They quickly see through speculation or legally-constrained information. Access to the practitioner(s) involved (the second victim(s)) can generate ‘real’ information.

They need an opportunity to tell their story. The incident likely disrupted their trust in the system or its practitioners. Telling the story can help them integrate the incident into their worldview.

First victims need to regain control over their experiences and emotions. Empowerment is possible by involving them in the restorative justice process.

They need restitution. Where an actual loss cannot be compensated, first victims want to know that everything is done to prevent recurrence. They don’t want others to suffer like they did.

Second victims typically need an opportunity to tell their story, to give their account of what happened. They may need anything from empathy to counseling to trauma care.

They likely need help transforming their guilt and shame into actions that help them, and their first victims and community, heal. What that means depends on your organization, the work, the incident, and the needs of first victims’ and community. This could involve meeting the first victims.

Second victims need to regain trust in their own competencies, and rebuild relationships with others who rely on them. They want reassurance that they, and their community, have done everything to prevent recurrence.

Your organizational community also has needs. Information about what happened and the response, for instance. But also an opportunity to help first and second victims, restoring relationships and trust, and a sense of joint problem ownership and community.

Wrongs or harms result in obligations. These obligations can be met by different stakeholders, in collaboration.

The practitioner (or second victim) can embrace the obligation to:

honestly disclose his or her role in the incident and give an account to the others involved or affected.
recognize the needs of first victim(s), organization and community. Systems of open disclosure, for example, help meet many first victim needs.
show remorse and put things right with first victim, organization and community.
identify pathways to prevention in collaboration with first victim(s), organization and community.

The organization and community can embrace the obligation to:

offer support to first and second victims (like open disclosure or critical incident and stress management programs).
not fire or sanction people, and ask what is responsible for the incident, notwho.
perform a learning review that shows why it made sense for people to do what they did.
identify pathways to prevention in collaboration with first and second victim(s).

The first victim typically has an obligation to:

respect the humanity of the practitioner involved in the incident.
be willing to be part of the solution.

Making amends for what has gone wrong is an important obligation. In restoration, this means promoting responsibility, reparation and healing for allinvolved in the incident. Do everything to reintegrate the practitioner into the community. Do not estrange the practitioner by just sanctioning them. It erodes trust and relationships by only creating more hurt, without healing.

Restoration asks you to:

Address the harm done to first and second victims of the incident, as well as the surrounding community.
Address the causes of the incident by asking what was responsible for it, so that other practitioners do not get put in the same position.

Restoration relies on collaboration, inclusion and engagement. An incident can affect many people, and has many stakeholders. These need to be given access to, and information about, each other so that all can be involved in deciding what justice requires in their case.

This may mean an actual dialogue between parties (e.g. first and second victim), to share their accounts and arrive at an agreement of what should be done.

How might the creation of restorative justice look in your organization? It will likely involve the following steps and people:

Encounters between stakeholders. The first one is likely to be between your organization and the practitioner(s) involved in the incident. Remember your organization’s obligations above! An encounter between first and second victim, appropriately guided, may follow. Surrogates or representatives may need to be used in some situations.
Encouraging all stakeholders to give their accounts, ask questions, express feelings and work toward a mutually acceptable solution.
Acknowledge the harm, restore the balance and address your future intentions.

To succeed, you will need to broaden out the conversation about a restorative just culture. Include senior management, the board, your regulators, HR, your safety department, unions or professional associations, customers, and other stakeholders.

Ask yourself these questions to check how close you might be:

Does your just culture process address harms, needs and causes?
Is it adequately victim-oriented?
Are practitioners encouraged to see their contribution, but also treated as potential second victims?
Are all relevant stakeholders involved?
Is it based on dialogue, participation and collaborative decision-making?
Does it address causes?
Is it respectful to all parties?