Nurses’ Perceptions of a Just Culture and Its Influence on Error Reporting Behaviors

Introduction

Accurate and complete reporting of clinical errors and near-miss events is foundational to organizational learning in healthcare, providing the data necessary to identify systemic vulnerabilities, evaluate the effectiveness of safety interventions, and prevent recurrence of harm. Despite the well-established importance of reporting to patient safety improvement, substantial underreporting remains a persistent and well-documented problem, with estimates suggesting that a large majority of clinical errors, and an even larger majority of near-miss events, are never formally reported through institutional incident reporting systems (Vrbnjak et al., 2020). This gap between the true incidence of error and the incidence captured through reporting systems represents a significant blind spot for hospital safety efforts, as unreported events remain unavailable for systemic analysis and corrective action.

A substantial body of research has identified fear, particularly fear of disciplinary action, blame, or damage to professional reputation, as among the most consistently cited barriers to error reporting among nursing staff (Hwang & Lee, 2017). In response to this evidence, healthcare organizations have increasingly adopted the principles of just culture, a framework originally articulated in aviation and other high-reliability industries and subsequently adapted for healthcare, which seeks to distinguish between human error, at-risk behavior, and reckless conduct, and to calibrate organizational response, ranging from consolation and system redesign to coaching or disciplinary action, according to this distinction rather than applying uniform punitive consequences to all adverse outcomes (Marx, 2019; Boysen, 2013). The theoretical premise of just culture is that when staff perceive that honest disclosure of error will be met with a fair and proportionate response rather than automatic blame, they will be more willing to report events that would otherwise remain hidden.

While just culture has achieved widespread endorsement as a stated organizational value across many healthcare systems, evidence suggests that the gap between formal policy adoption and frontline staff perception of a genuinely operating just culture can be substantial. Several studies have found that nurses’ perceptions of their organization’s actual practice of just culture principles vary considerably even within institutions that have formally adopted just culture policy language, and that this perception gap, rather than the mere existence of a stated policy, may be the more proximate determinant of reporting behavior (Wu et al., 2017; Petschonek et al., 2019). However, much of the existing evidence linking just culture perception to reporting behavior has relied on either qualitative interview methods with limited generalizability or survey instruments that did not directly link perception scores to objectively verifiable reporting outcomes, leaving open questions regarding the strength and consistency of this association when examined using validated, quantitative measures.

Given the persistent problem of error underreporting and the theoretical centrality of just culture perception as a proposed remedy, further quantitative evidence directly examining the relationship between nurses’ perceived just culture and their self-reported reporting behavior, using validated measurement instruments, is warranted. The purpose of this study was to examine registered nurses’ perceptions of just culture within their organization and to evaluate the association between these perceptions and self-reported frequency of error and near-miss reporting, while also characterizing the specific barriers to reporting cited by nurses with differing levels of just culture perception.

Methods

This study employed a cross-sectional, correlational survey design conducted across six inpatient units, spanning medical-surgical, telemetry, and critical care service lines, located within two acute care hospitals in the same regional health system. All registered nurses providing direct patient care on the participating units were eligible for inclusion. Nurses in purely administrative or educator roles without direct clinical assignment were excluded. Recruitment occurred through unit-based email invitation and staff meeting announcements over a 6-week data collection period, with participation being voluntary and anonymous. A total of 312 registered nurses completed the survey, representing an estimated response rate of 61% of eligible staff across the participating units.

The survey instrument incorporated three validated measurement components. Just culture perception was assessed using the Just Culture Assessment Tool, a validated instrument measuring nurses’ perceptions across domains including trust in fair treatment following error disclosure, perceived organizational learning orientation, and perceived psychological safety in raising safety concerns. Broader patient safety culture context was assessed using the reporting-related subscales of the Hospital Survey on Patient Safety Culture (HSOPSC), including the “nonpunitive response to error” and “frequency of events reported” subscales. Self-reported reporting behavior was assessed using items asking respondents to indicate the number of near-miss events and the number of actual errors they had personally observed or been involved in over the preceding six months, and the number of these events they had formally reported through the institution’s incident reporting system.

Three primary analytic variables were derived from the survey data:

1.A composite just culture perception score, calculated from the Just Culture Assessment Tool, with respondents subsequently categorized into high, moderate, and low perception tertiles for descriptive comparison in addition to being analyzed as a continuous variable.

2.A binary near-miss reporting outcome, indicating whether the respondent reported having formally disclosed at least one near-miss event through the incident reporting system during the preceding six months, among respondents who indicated having observed or been involved in at least one such event.

3.An open-response item asking respondents to identify, from a structured list, the barriers that had most influenced their decision not to report an event when they chose not to, allowing for characterization of barrier type by just culture perception tertile.

Multivariate logistic regression was used to examine the association between just culture perception score and the likelihood of near-miss reporting, adjusting for years of nursing experience, unit type, and prior personal involvement in a formally reported incident. Multivariate linear regression examined the association between just culture perception score and self-reported reporting frequency as a continuous outcome. Statistical significance was set at p < .05, and analyses were conducted using Stata version 18.

Results

Respondent characteristics were broadly representative of the eligible nursing population across the participating units, with a mean of 8.6 years of nursing experience (SD = 6.9) and representation across all three service lines. Approximately 61% of respondents indicated having personally observed or been involved in at least one near-miss event during the preceding six months, and 74% indicated having observed or been involved in at least one actual error event during the same period.

Just culture perception scores demonstrated substantial variation across respondents despite all participating units operating under a formally adopted, system-wide just culture policy. Among nurses who had observed or been involved in a near-miss event, those in the highest just culture perception tertile were significantly more likely to report having formally disclosed that event compared to those in the lowest tertile, at 68.4% versus 31.2% respectively. In the adjusted logistic regression model, higher just culture perception score was independently associated with substantially greater odds of near-miss reporting (adjusted odds ratio = 3.86, 95% CI 2.41–6.18, p < .001), after adjusting for years of experience, unit type, and prior involvement in a formally reported incident.

Analysis of self-reported barriers to reporting revealed a distinct pattern by just culture perception tertile. Among nurses in the lowest perception tertile, fear of disciplinary action (cited by 74% of non-reporters in this group) and fear of blame or judgment from colleagues or leadership (cited by 66%) were the most frequently endorsed barriers. Among nurses in the highest perception tertile, these fear-based barriers were substantially less prevalent, cited by 22% and 18% respectively; instead, the most frequently cited barriers among this group were administrative burden associated with the reporting process (cited by 51%) and lack of feedback or perceived follow-through following prior reports (cited by 44%), suggesting that among nurses who trust the organizational response to error, remaining barriers shift from fear-based to process-based concerns. The multivariate linear regression model examining reporting frequency as a continuous outcome similarly demonstrated a significant positive association between just culture perception score and self-reported reporting frequency (standardized β = 0.41, p < .001), independent of years of experience and unit type.

Discussion

The findings of this study demonstrate a strong and independent association between nurses’ perceived just culture and their self-reported likelihood of formally disclosing near-miss events, with nurses reporting high just culture perception scores more than three times as likely to report a near-miss compared to those reporting low perception scores. This finding is consistent with, and extends through quantitative confirmation, prior qualitative and mixed-methods work suggesting that perceived psychological safety and trust in fair organizational response function as central determinants of reporting behavior (Wu et al., 2017; Petschonek et al., 2019).

The substantial variation in just culture perception observed across respondents, despite all participating units operating under a common, formally adopted system-wide just culture policy, carries important implications for healthcare organizations seeking to improve reporting completeness. This finding suggests that the formal existence of a just culture policy at the organizational level does not automatically translate into a consistent, lived experience of psychological safety among frontline staff, and that unit-level culture, leadership behavior, and the specific manner in which individual error events are handled following disclosure may exert a stronger influence on staff perception than policy language alone. This is consistent with theoretical accounts of just culture implementation emphasizing that the framework’s safety benefit depends substantially on consistent, visible application by frontline leaders at the point of individual case handling, rather than on policy adoption in isolation (Marx, 2019; Boysen, 2013).

The distinct shift in cited reporting barriers observed between low- and high-perception nurses, from predominantly fear-based concerns to predominantly process-based concerns such as administrative burden and lack of feedback, offers a useful roadmap for organizations at different stages of just culture maturity. For organizations where fear of blame remains the dominant barrier, efforts should prioritize visible, consistent leadership behavior demonstrating fair and proportionate response to disclosed error. For organizations that have made greater progress in establishing psychological safety, as reflected in higher just culture perception scores, further gains in reporting completeness may depend more on streamlining the reporting process itself and ensuring that staff receive timely, meaningful feedback regarding the outcome and organizational learning resulting from their reports, a factor that has been separately identified as important for sustaining staff engagement with reporting systems over time (Vrbnjak et al., 2020).

This study has several limitations. The cross-sectional design precludes causal inference regarding the direction of the observed association, and it remains possible that nurses with a general disposition toward reporting also perceive their organizational culture more favorably, rather than perception driving reporting behavior exclusively. Reliance on self-reported reporting behavior, rather than objectively verified linkage to the institution’s incident reporting database, introduces the possibility of recall or social desirability bias, though the anonymous survey design was intended to mitigate this concern. The two-site setting may limit generalizability to organizations with substantially different safety culture maturity or leadership structures. Future research employing longitudinal designs, and directly linking survey-based just culture perception measures to objectively verified incident reporting system data, would strengthen causal inference regarding this relationship. Despite these limitations, the strength and consistency of the observed association support continued organizational investment in just culture implementation, with particular attention to the consistency of frontline leadership response to disclosed error as a likely determinant of whether formally adopted just culture policy translates into a genuinely perceived, and behaviorally influential, organizational culture.

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