Just Culture in Healthcare: Building Safer, Fairer and More Learning-Focused Organisations
Healthcare is complex. Patients’ needs vary, teams work under pressure, decisions are made in changing conditions, and care is delivered through systems that depend on people, processes, equipment, information, environments and leadership working together. When things go wrong, the way an organisation responds matters.
A just culture helps healthcare organisations respond to patient safety incidents, serious incidents, never events, complaints, clinical concerns and everyday risks in a way that is fair, compassionate and focused on learning. It moves the organisation away from knee-jerk blame and towards a deeper understanding of how work is really done, why decisions made sense at the time, and what needs to change to make care safer.
At Promethean HD, we support NHS and healthcare organisations to strengthen patient safety culture through human factors, PSIRF training, patient safety incident investigation training, governance support, restorative practice and practical culture improvement programmes. Our focus is simple: helping organisations learn well, treat people fairly and design safer systems of care.
What is a just culture?
A just culture is often described as a culture of trust, learning and accountability. It recognises that most patient safety incidents are not caused by one person simply choosing to do the wrong thing. They usually arise from the interaction between human performance, work conditions, system design, organisational pressures, communication, leadership, staffing, equipment, policies and competing priorities.
James Reason described just culture as one part of a wider safety culture, alongside an informed culture, reporting culture, learning culture and flexible culture. In this model, a just culture creates the conditions where people feel able to raise concerns, report errors and discuss near misses, while still recognising that there must be a fair boundary between acceptable and unacceptable behaviour.
This is why just culture is not the same as a “no blame” culture. A no blame culture can unintentionally ignore the need for professional accountability. A blame culture, on the other hand, encourages defensiveness, silence and under-reporting. A just culture sits between these extremes. It seeks to understand the system first, support those affected, and respond proportionately where individual conduct, health, competence or deliberate harm may genuinely need to be considered.
Retributive justice and restorative justice: what do they mean?
A retributive approach focuses on using punishment to address performance. It can arguably be necessary in rare situations involving deliberate harm, wilful misconduct, criminal behaviour, serious professional misconduct or reckless disregard for safety. However, if it becomes the default response to patient safety incidents, it can close down learning.
A restorative approach focuses on restoring people and situations back to healthy conditions, with a focus on actions to put things right. It does not remove responsibility. Instead, it reframes accountability as something people actively participate in: telling the truth, listening to those affected, helping repair harm and contributing to safer systems.
A healthcare organisation Just culture, continuous improvement and learning cultures
With a mature learning culture does not simply investigate harm after it occurs. It learns from everyday work, excellence, complaints, staff concerns, patient experience, audit, outcomes, inequalities, operational pressures and weak signals. It uses this intelligence to improve the design of care.
This links directly to continuous improvement. If people feel safe to speak up, leaders can identify risks earlier. If investigations focus on systems rather than blame, actions are more likely to address contributory factors. If staff and patients are involved in learning, improvement plans are more likely to be realistic, compassionate and sustainable. A just culture is at the heart of the Human Factors approach. To learn more about Human Factors, click here. To learn more about Human Factors in Healthcare, click here.
NHS England: from the Just Culture Guide to the Being Fair tool
NHS England has used several resources to support just culture and fair decision-making.
The earlier NHS Just Culture Guide, published in 2018, was based on James Reason’s incident decision tree and was designed to support consistent, constructive and fair evaluation of staff actions following patient safety incidents. It was intended to help managers consider whether individual support or intervention was needed, while recognising that action singling out an individual is rarely appropriate because most patient safety issues have deeper system causes.
NHS England later reviewed the Just Culture Guide in the context of PSIRF and found that it was no longer fit for purpose. Following a discovery phase, stakeholder engagement, workshops and testing with pilot organisations, NHS England replaced the Just Culture Guide with the Being Fair tool, published in May 2025.
The Being Fair tool should only be used when concerns about an individual’s conduct or fitness to practise are raised during a patient safety learning response. It is not for routine use. NHS England emphasises that patient safety incidents are usually signs of underlying systemic issues requiring wider system action, and that singling out an individual is rarely appropriate.
The Being Fair tool includes decision points such as the substitution test, foresight test, deliberate harm test, health test and mitigating circumstances. Importantly, it also reflects restorative thinking by asking, before using the tool, who is hurt, what they need and whose responsibility it is to meet that need.
This represents a significant development in NHS England’s approach: from a decision-tree model focused on fair individual assessment, towards a more explicit PSIRF-aligned, systems-based and restorative approach.
What national reports tell us about culture, silence and failure to learn
Repeated healthcare inquiries and reviews have shown that poor culture is not a soft issue. It is a patient safety issue.
The Francis Inquiry into Mid Staffordshire described serious failures in care and highlighted the need for openness, transparency, candour, compassionate leadership and a fundamental change in NHS culture.
The Berwick Review argued that the NHS should abandon blame as a tool, trust the goodwill and good intentions of staff, embrace transparency, place patient safety above all other aims, and build capability for continuous improvement.
The Ockenden Review into maternity services at Shrewsbury and Telford found that services failed to investigate, failed to learn and failed to improve, with consequences for mothers, babies and families.
The Kirkup Review into maternity and neonatal services in East Kent identified the need for the NHS to be better at identifying poorly performing units, giving care with compassion and kindness, teamworking with a common purpose, and responding to challenge with honesty.
The national maternity and neonatal investigation chaired by Baroness Valerie Amos has also highlighted recurring concerns about families not being listened to, lack of compassion, reluctance to admit mistakes and say sorry, poor accountability, and the impact of racism, discrimination, culture and leadership on maternity safety.
These reports point to a consistent message: when organisations become defensive, hierarchical or closed, harm can be repeated. When patients, families and staff are not heard, opportunities to learn are missed. When leaders focus on reputation management rather than truth and improvement, trust is damaged.
A just culture is one way organisations can actively resist these patterns.
What does a good culture look and feel like?
A good culture is felt in everyday interactions.
For staff, it feels safe to ask questions, raise concerns, admit uncertainty, report incidents and describe the gap between policy and reality. Leaders are visible, curious and fair. Teams are supported to learn, not shamed for speaking up. Accountability is clear, but it is not driven by fear.
For patients, families and service users, a good culture feels honest, compassionate and responsive. People are listened to. Concerns are taken seriously. Explanations are clear. Apologies are meaningful. When harm occurs, the organisation does not close ranks; it engages, investigates proportionately, shares learning and takes action.
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People are treated with dignity after incidents
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Leaders ask “what happened?” before asking “who is responsible?”
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Patients and families are partners in learning
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Staff can speak up without fear of retaliation
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Poor behaviour is addressed fairly and consistently
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Improvement actions are practical, owned and monitored
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Governance connects board assurance with frontline reality
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Psychological safety and professional accountability work together
This kind of culture improves more than staff experience. Service users benefit from safer systems, better communication, more reliable services, earlier recognition of risk and organisations that are willing to learn before harm is repeated.
How Promethean HD can support your organisation
Promethean HD helps healthcare organisations assess, understand and improve culture using human factors, systems thinking, governance expertise and practical improvement methods.
Culture assessment and diagnostic reviews
We help organisations understand what their culture looks and feels like in practice. This may include interviews, focus groups, observation, document review, governance review, incident review, staff engagement, patient safety data and board-level assurance mapping.
Just culture and restorative practice development
We support teams and leaders to define what just culture means locally, align policies and behaviours, and develop restorative approaches that are compassionate, fair and practical.
PSIRF training and patient safety incident investigation training
We provide PSIRF training, patient safety investigation training and learning response development so teams can apply systems thinking, human factors and compassionate engagement in real-world healthcare settings.
Being Fair tool implementation support
We help patient safety, governance, HR, workforce and clinical leadership teams understand how the NHS England Being Fair tool should be used, when it should not be used, and how to align it with PSIRF, learning responses and organisational policy.
Serious incident, never event and learning response support
We support organisations to review serious incidents, never events, complaints and complex patient safety events in a way that strengthens learning, improves action design and avoids simplistic blame.
Governance and board assurance
We help boards and senior leaders connect patient safety culture with governance, assurance, risk management, regulatory expectations, CQC readiness and continuous improvement.
Improvement planning and culture reform
Assessment alone does not change culture. We work with organisations to create practical improvement plans, develop internal capability, support leaders and teams, and measure whether changes are making a difference.
Build a safer, fairer and more open healthcare organisation
A just culture is not created by a policy, a poster or a single training session. It is created through repeated leadership decisions, fair responses to incidents, meaningful engagement with patients and families, and a commitment to learning from how care is really delivered.
Promethean HD can help your organisation move from aspiration to implementation.
Whether you are strengthening PSIRF, reviewing serious incidents or never events, implementing the Being Fair tool, developing a restorative just culture, or responding to concerns about openness, silence or blame, we can help you understand your current culture and design a practical route to improvement.
From James Reason to Sidney Dekker: how just culture has developed
The early development of just culture is strongly associated with Professor James Reason, whose work on organisational accidents, human error and safety culture has shaped safety thinking across aviation, healthcare and other safety-critical industries. Reason’s model helped organisations recognise that unsafe acts often occur within wider system conditions, and that learning depends on staff feeling able to report and discuss safety concerns without fear of unfair punishment.
Over time, just culture thinking has continued to develop. Sidney Dekker has been particularly influential in shifting the conversation from traditional disciplinary models towards restorative just culture. Dekker challenges organisations to look beyond the question, “Who broke the rule and what punishment is deserved?” and instead ask: “Who was harmed, what do they need, and whose responsibility is it to meet those needs?”
This is an important shift for healthcare. After harm, many people may be affected: patients, families, staff involved in the event, colleagues, managers and wider teams. A restorative approach recognises that learning cannot be separated from compassion, trust and repair. It encourages organisations to focus on truth, openness, emotional impact, accountability, improvement and the restoration of relationships wherever possible.
Why just culture matters for patient safety
A just culture improves patient safety because it helps organisations see more. When staff are afraid of blame, they may hesitate to report incidents, near misses, weak signals or unsafe conditions. When they trust that concerns will be treated fairly, organisations gain better information about risk, work-as-done and the pressures affecting safe care.
This is central to the Patient Safety Incident Response Framework (PSIRF). PSIRF moves away from reactive, investigation-heavy approaches and encourages proportionate learning responses, compassionate engagement, systems thinking and improvement. A just culture supports this by creating the conditions where learning responses can be open, honest and useful rather than defensive. To read more about PSIRF click here. To read more about what PSIRF training and education entails, click here.
The impact of a just culture
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Better reporting of incidents, near misses and risks
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More open conversations about work pressures and system weaknesses
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More meaningful patient safety investigations and learning responses
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Reduced fear among staff involved in incidents
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Greater trust between staff, leaders, patients and families
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Improved action design and stronger continuous improvement
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A clearer distinction between system learning and genuine conduct concerns
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A stronger foundation for high reliability, governance and assurance
NHS England, NHS Wales and NHS Scotland: different approaches to just culture
Across the UK, just culture is recognised as important, but each nation has developed its own emphasis.
NHS England
NHS England’s current approach is closely linked to PSIRF, patient safety culture improvement, restorative practice and the Being Fair tool. Its guidance encourages organisations to move towards a just and restorative culture that focuses on understanding and learning, rather than blame.
NHS Wales
NHS Wales, through Improvement Cymru, provides a dedicated Just Culture Guide that explains just culture as part of a wider safety culture. The guide draws on James Reason’s five components of safety culture: informed, reporting, just, flexible and learning cultures. It describes just culture as a fair culture where staff are not unfairly blamed for incidents that were not their fault, while still being held accountable where there is evidence of wilful misconduct or gross negligence.
NHS Scotland
NHS Scotland resources, including Turas learning materials, place just culture within a wider culture of openness and learning. The Scottish materials emphasise that a culture of fear and blame is toxic to patient safety and highlight the importance of managing adverse events well, supporting openness and embedding learning.
Although the language and tools vary, the direction of travel is consistent: healthcare organisations need cultures where staff can speak up, patients and families are heard, incidents are examined honestly, and learning leads to safer care.
Just Culture in Healthcare