Why Just Culture Isn’t Sticking

by Tom Geraghty

What Do We Mean by “Just” Culture?

The concept of a “Just Culture” was first developed in James Reason’s 1997 book Managing the Risks of Organisational Accidents. When we say “Just Culture”, we’re using “just” as in “justice”, not “just” as in “only”. And that itself can lead to some misinterpretations of what a Just Culture actually means. For many of us, the concept of justice is intertwined with the primarily retributive model that we’re familiar with in society (you do wrong, you get punished) – and so we might assume a Just Culture is largely about retribution. But actually, the justice in Just Culture aligns much more closely with a restorative model of justice. More on that later.

Reason argued that Just Culture is essential for a reporting culture, where people feel safe to report incidents, near misses, and unsafe conditions. Without reporting, we can’t learn from things that happen: which means that mistakes keep happening, safety doesn’t improve, and people suffer harm as a result. Reason framed Just Culture as a core component of a broader “safety culture” (and there’s a correlating debate about what “safety culture” is or if it even exists…). 

David Marx later expanded this thinking into healthcare in his 2001 report Patient Safety and the “Just Culture”: A Primer for Health Care Executives, helping to establish Just Culture as a key approach for learning from harm and building safer systems in complex, high-consequence environments. Since then Sidney Dekker has spoken and written extensively on Just Culture, including his excellent 2007 book Just Culture: Balancing Safety and Accountability. Dekker describes that Just Culture promotes learning, justice and safety, and reminds us that we can choose to be either backward-looking and retributive, or forward-looking and change-oriented.

Despite much effort, many organisations struggle to embed Just Culture effectively and sustainably. Many of our clients, particularly in healthcare, find it difficult, even after months and years of hard work, to make Just Culture “stick”. That’s where our work on fostering psychological safety comes in. 🙂

Balancing Accountability and Learning

While perhaps most widely adopted in healthcare, Just Culture is also applicable across aviation, industry, and other safety-critical sectors. It is designed to balance accountability with learning, recognising that humans will inevitably make mistakes and that punitive responses often obstruct meaningful improvement. Instead, Just Culture promotes systems that treat individuals with fairness and compassion. Learning and restoration are considered more important than blame and punishment. 

The tragic case of Elaine Bromiley is a key example of this: Elaine, a healthy woman undergoing a routine operation, died following complications with airway management when her team of doctors became fixated on a single procedure (intubation). Although nurses present recognised the escalating danger, they did not speak up, held back by the steep power gradient between the doctors and the nurses present. Elaine’s death prompted her husband Martin, an airline pilot with expertise in human factors, to found the excellent Clinical Human Factors Group, or CHFG, which works to ensure that lessons are learned and tragedies like this are not repeated. Rather than focusing on blame or punishment, Elaine’s story highlights the need for a Just Culture – one that enables open, candid and timely communication, supports learning from mistakes, recognises and cares for both the patients harmed (“first victims”) and the staff involved (“second victims”), and ultimately focuses on preventing future harm.

An important principle contained within Just Culture is local rationality: people make decisions that seem entirely rational to them at the moment given their immediate context, knowledge, and understanding. The opposite of local rationality is the “fundamental attribution error”, which seduces us to blame people’s character or competence instead of recognising contextual or systemic influences. 

Unless we assess actions through the lens of local rationality (understanding what seemed reasonable to that person at that time) we risk applying hindsight and outcome bias and using counterfactual phrases like “if only they’d…” or “they should have…”. These undermine psychological safety and restrict our ability to learn from failures. 

It’s worth acknowledging that much of the disconnect between what we think ‘should’ have happened, with the benefit of hindsight, and what actually happened is also driven by a gap between ‘work as imagined’ and ‘work as done’. Rules and procedures are often written with ideal scenarios in mind, not the messy, complex, resource-constrained, high-pressure conditions of real work, and thus very often, work is not happening day-to-day as we imagine it is. People often need to find workarounds just to get the work done. When things go wrong, we should ask: were individuals deviating from rules because they were being reckless, or because the rules simply didn’t fit the reality? How often has this rule been broken and resulted in a good outcome? Just because this time a deviation resulted in a poor outcome, it doesn’t necessarily mean that deviating from the rules is the problem.

Why Blame Gets in the Way

While a restorative Just Culture isn’t necessarily blame-free, and nor is it about polarising people against systems, it is about recognising that people operate within systems. Mistakes often reflect systemic issues rather than isolated individual failings. Healthcare professionals need robust systems and supportive processes to perform at their best. At its core Just Culture suggests that in most cases, blame is the enemy of safety, advocating instead for open, fair, and restorative responses to mistakes. This challenges our instinctive inclination towards ‘blametropism’ – the tendency to immediately seek someone or something to blame whenever something goes wrong. Overcoming this natural impulse is fundamental to fostering genuine learning and restoration. 

“Being blamed in the context of a safety investigation is contrary to the purpose of a safety investigation, partly because it is deathly for an occurrence reporting system, and for any subsequent investigations and learning.” – Steven Shorrock [link[

The Restorative Approach to Accountability

A critical element of Just Culture is its restorative aspect, ensuring that those harmed by mistakes (patients, families, and also colleagues – the “second victims”) feel heard, understood, and supported, rather than ignored or dismissed. Dekker emphasises that a restorative Just Culture centres on understanding who was hurt, identifying their needs, and determining whose obligation it is to meet those needs. 

This calls for a rethinking of accountability: not as a matter of identifying who broke the rules or who was last in contact with the patient in order to assign blame or punishment (a retributive model), but instead as a process of exploring who was harmed, identifying their needs, and taking responsibility for addressing those needs (a restorative model). In this restorative context, “accountability” means something different to assigning fault – it’s about seeking ‘an account’ of what happened – something that we can use to improve our understanding and learn from. It’s certainly not something that’s used to impose punishment. In a truly restorative culture, those involved in an incident welcome the opportunity to participate in this process, which both rebuilds trust for those involved and/or harmed, and provides a powerful opportunity for both individual and collective learning.

A culture cannot claim to be ‘Just’ if it further harms the people it exists to care for. Too often, patients and families are retraumatised by defensive institutional responses that prioritise self-protection – whether reputational or legal – over honesty, empathy, and healing. A truly restorative Just Culture centres the needs of those harmed, responding with transparency, compassion, and meaningful long-term support, rather than defensiveness.

The NHS’s Patient Safety Incident Response Framework (PSIRF) makes this relationship explicit: it recognises that psychologically safe cultures and behaviours must be in place before approaches like Just Culture can take root. PSIRF signals a significant shift in mindset from “accountability” to learning, and from individual failure to systemic understanding. But frameworks like PSIRF and resources like the NHS “Being Fair” tool, without practical action, structural and systemic change, are unlikely to be enough to change the experience of people at the sharp end, and the patients they serve. 

Beyond “What’s gone wrong?”

One challenge is that we can (and should) also learn from what goes right as well as what goes wrong. Studying everyday work, especially when things succeed despite challenging conditions, can uncover the adaptations, relationships, and quiet brilliance that make systems resilient. Just Culture tends to lean towards (at least in practice) primarily learning from failures. We would benefit from changing the primary trigger for learning investigations from the amount of harm caused to the learning potential of the event. Not all incidents are equally useful for learning. The most valuable insights often come from “Goldilocks events”: not too big, not too small, not too rare, and not too politically sensitive to explore with honesty. Just Culture must recognise this if it’s to become more than solely a reactive approach.

And when we start to expand out our view of what Just Culture is and can be, you might notice how well it aligns with the Human and Organisational Performance (HOP) principles:

• People make mistakes
• Blame fixes nothing.
• Context drives behaviour
• Learning is vital
• Response matters

The Challenge of Embedding Just Culture

Many organisations enthusiastically attempt to implement Just Culture practices, such as open reporting systems, restorative meetings, or non-punitive investigations. Yet frequently, these practices don’t ‘stick’. People and teams may gradually and insidiously revert to previous, more punitive methods of dealing with errors. The underlying reason is often that practices and tools have been imposed without establishing the necessary foundational culture.

At an organisational level, it’s necessary to consider the four lenses of organisational change: Values, Behaviours, Practices, and Systems and Structures. If we neglect just one of these lenses when we’re considering change, it won’t be sustainable.

In other words, simply imposing Just Culture mechanics into an existing system, without first addressing how the deeper shared values, behaviours, practices work alongside organisational systems and structures, is like building a car but forgetting to put the fuel in. It might look right, but it won’t run.

Lessons from NUMMI and the Importance of Culture

All this reminds me of the NUMMI (New United Motor Manufacturing, Inc.) plant in California during the 1980s – a joint venture between General Motors and Toyota. The project aimed to revitalise an underperforming GM factory by introducing Toyota’s Production System (TPS), including tools like the Andon Cord, which allows workers to stop the production line to address issues immediately.

What made NUMMI successful wasn’t just the introduction of these tools, but Toyota’s committed investment in building a culture of continuous improvement, collective responsibility, and psychological safety. Employees received extensive training, including two-week immersions in Japan, to help shift not only their skills but also their beliefs and behaviours. The focus wasn’t on control, but on equipping and trusting workers to do quality work.

However, GM later failed to replicate this success in other plants. They tried to adopt the surface-level practices of TPS without the cultural transformation that underpinned them. In Detroit, for example, workers ignored the new tools because the deeper cultural changes – trust, respect, and shared ownership – had never been made. What changed the culture at NUMMI wasn’t just practices or process, it was genuinely giving people the means and understanding by which they could successfully do their jobs.

Structural Barriers and Power Dynamics

In healthcare, structural and systemic barriers frequently impede the adoption of Just Culture principles. Entrenched hierarchies, power gradients between consultants and other frontline staff, and bureaucratic “accountability” practices create environments where mistakes are often hidden rather than explored. When something goes significantly wrong, there is often a belief that someone must be held “accountable” – whether that’s someone at the sharp end (a clinical practitioner, for example) or at the blunt end (a senior exec, for example). Media coverage also plays a large role in organisational behaviour: while it is often essential in exposing harm and giving voice to victims, it can also promote simplistic, blame-heavy narratives. Just Culture cannot survive in environments dominated by headline-driven scapegoating.

Even when organisations adopt Just Culture principles internally, their efforts are often undermined by broader legal, regulatory, and even media pressures. A clinician may face a compassionate, system-focused local learning investigation, and simultaneously endure a distressing coroner’s inquest that feels punitive, or a professional referral process that focuses narrowly on individual fault. Until our wider systems are reformed to align with Just Culture principles, fear of negative repercussions from admitting mistakes and raising concerns will persist.

Implementing Just Culture Successfully

To successfully embed Just Culture, we need to create the underlying conditions for it to persist sustainably. Psychological safety is the substrate in which a Just Culture thrives. Without psychological safety, employees remain reluctant to admit errors, speak openly about risks, or participate in restorative processes.

We often see this disconnect clearly in practice. Organisations may adopt Just Culture principles and practices superficially, yet fail to cultivate the underlying beliefs, norms, and day-to-day interactions that genuinely enable it. These foundational elements include:

1. Reduce power gradients.
2. Establish shared behavioural norms.
3. Build systems that reward open communication and candour.
4. Address problematic behaviour.
5. Recognise that psychological safety looks different for everyone.
6. Tackle structural and systemic barriers.

Ultimately, Just Culture thrives in environments where psychological safety serves as the foundation. Without psychological safety, efforts to embed Just Culture remain well-intentioned but ultimately superficial. We all learn by making mistakes, but we don’t have time to make every mistake ourselves – so we need to learn from those of others. The power of a psychologically safe, restorative Just Culture lies in creating a space where people can tell their stories, with all the messy details, and share that valuable learning with others without fear of humiliation or retribution. 

References and further reading:

James Titcombe: Talk of Just Culture Without System Change Is a False Promise: https://patientsafetyfirst.wordpress.com/2025/05/16/we-cant-talk-about-just-culture-without-changing-the-system-around-it/

Being fair tool: Supporting staff following a patient safety incident: https://www.england.nhs.uk/publication/being-fair-tool/

PSIRF: The Patient Safety Incident Response Framework: https://psychsafety.com/psirf/

John Shook: How NUMMI Changed Its Culture: https://www.lean.org/the-lean-post/articles/how-nummi-changed-its-culture/

Dekker, S: Just Culture | Balancing Safety and Accountability https://ndl.ethernet.edu.et/bitstream/123456789/20186/1/118.%20Sidney%20Dekker.pdf

Dekker, S: Just Culture: who gets to draw the line? https://www.humanfactors.lth.se/fileadmin/lusa/Sidney_Dekker/articles/2008/JustCultureCTW.pdf

Shorrock, S. Just Culture: Who Are We Really Afraid Of? https://humanisticsystems.com/2016/11/24/just-culture-who-are-we-really-afraid-of/ 

Main article photo by Pavel Danilyuk

Psychological Safety in Practice

Tackling inequalities in maternity care

This excellent in-depth piece describes how UK maternity services face deep inequalities that undermine both patient safety and staff wellbeing: mothers in poor areas and Black women suffer far higher rates of loss and complications, while maternity teams struggle under staffing shortages and burdensome reporting requirements. In this piece, NHS Trust leaders agree that building psychological safety and a culture of open, blame-free learning can dramatically improve experiences and outcomes.

Improvement will require adequate resourcing, clear national frameworks and systemic change.

“Birth is neither inherently safe nor dangerous – it is both until reality declares otherwise.” (Titcombe, 2014).

“Deferential Speech Syndrome” (DSS) in surgical operating theatres

In this paper, Jennifer Dunn introduces what she terms “Deferential Speech Syndrome” (DSS) – the tendency of team members to soften or suppress the communication in the face of a power gradient. Cases such as Elaine Bromiley (above) demonstrate how critical this effect can be. DSS (also known as “attenuated voice”, or “safety silence” elsewhere) is, simply, the opposite of psychological safety.

Drawing on lessons from high-reliability industries, Dunn shows how aviation’s Crew Resource Management (CRM) and nuclear power’s layered decision-protocols illustrate that flattening power gradients enhances both resilience and psychological safety in complex, high-consequence environments.

However, I’m not a fan of the pathologisation of deferential speech as a “syndrome” because it implies an individualisation of the issue, rather than a reflection of systemic and contextual effects.

RDF 2025

This week I was lucky enough to deliver the first night keynote at RDF 2025 – the conference for professionals in health and care research. I also joined a wonderful panel of folks who shared powerful, insightful, and actionable stories of psychological safety and the impact it has on our lives as well as outcomes at work. Thanks so much to the organisers and everyone who made it a great success!

Employee “Free” Speech vs. Organisational Censorship on Social Media

Here’s an interesting paper. Censoring employees’ prejudiced social media posts has opposite effects on psychological safety depending on political ideology: it reassures some by signalling an inclusive, anti‐prejudice stance but alarms others who value absolute free‐speech autonomy. Through qualitative observational and experimental surveys, Solomon, Scott, and Hall demonstrate that this ideological split can be resolved not by “choosing sides” but by implementing specific, nuanced, policies.

Policies with clear anti‐prejudice values, that focus on genuinely threatening content (especially against traditionally marginalised groups) can uphold both employee well‐being as well as freedom of expression, and appear to improve psychological safety for folks across the political spectrum.

This week’s poem:

Extract from “An Essay on Criticism” by Alexander Pope

And while self-love each jealous writer rules,
Contending wits become the sport of fools:
But still the worst with most regret commend,
For each ill author is as bad a friend.
To what base ends, and by what abject ways,
Are mortals urg’d through sacred lust of praise!
Ah ne’er so dire a thirst of glory boast,
Nor in the critic let the man be lost!
Good nature and good sense must ever join;
To err is human; to forgive, divine.