Towards a Just Culture

The problem of a no-reporting culture is more than just not being “in the know.” In order to be able to learn and adapt as a humanitarian actor, data is needed on what goes wrong inside the organization. Because security systems are part of a continuously changing environment, they are – inherently – not flawless and will never reach a stable end-state. To stay attuned to reality, it is crucial that the security system is supplied with relevant information. This information can come from all kinds of sources, but above all it should come from your own aid and protection staff, as they are the ones working in the areas closest to the unsafety. The paradox is that staff members who benefit most from proper incident reporting seem to be the least motivated to contribute themselves to the collective system.

Why is that? Based on my experience, both fear and ignorance related to how individuals make sense of security incidents are contributing factors. Fear, because incidents are embarrassing and they can lead to punitive action – not reporting incidents saves your staff shame and punishment. Ignorance, because many feel that the high level of security standards at headquarters do not apply in the same way in the field. Therefore, staff members on the ground do not always register an incident as a reportable situation. Moreover, when an unsafe situation ends well, staff will often feel relieved and want to go back to work – they see no instant benefit or need to fill in forms for headquarters. If managers do not acknowledge that these factors are present in their organizations, they will not be able to get the right culture in place, where reporting is considered as part of being professional.

We can learn from the aviation and medical industries, where security incident reporting is part of the so-called “Just Culture.” Dr. James Reason at the Department of Psychology, University of Manchester, described a Just Culture as an atmosphere of trust in which people are encouraged, and even rewarded, for providing essential safety-related information, but in which they are also clear about where the line must be drawn between acceptable and unacceptable behavior.

Just Culture is not the same as a blame-free culture. Staff members are accountable for their actions, but there is a distinction between acceptable and unacceptable behavior, which is key to establishing such a culture. The Institute of Safe Medical Practices describes three different types of behavior related to security incidents. Each type has a different cause, which means that a different response is required.

Human error involves unintentional and unpredictable behavior that causes an undesirable outcome. It is not a behavioral choice – we do not choose to make errors. Discipline is not warranted or productive, because the worker did not intend the action or any undesirable outcome that resulted. In a Just Culture, the only just option is to console the worker who made the error and to redesign systems and processes to prevent further errors. At-risk behaviors are different than human errors. Research shows that human beings are programmed to drift into unsafe habits, to lose sight of the risk attached to everyday actions, or mistakenly believe the risk to be justified.

Our decisions on what is important are typically based on the immediate desired outcomes, not delayed benefits or uncertain consequences. Over time, as perceptions of risk fade away and workers try to do more with less, they take shortcuts and violate policies. These at-risk behaviors, often the norm among groups, are considered to be “the way we do things around here.” In a Just Culture, the solution is not to punish those who engage in at-risk behaviors, but to uncover and remedy the motives for their actions and to decrease group tolerance for taking these risks through team coaching.

Reckless behavior means that workers perceive the risk they are taking and understand that it is substantial. They behave intentionally and are unable to justify the conduct (they do not mistakenly believe the risk is justified). They know others are not engaging in the action: it is not the group norm. In a Just Culture, reckless behavior is blameworthy behavior. As such, it should be managed through remedial or disciplinary actions according to the organization’s human resources policies.

Acknowledging that there are problems with reporting within your organizations and that different types of behavior that lead to security incidents should be dealt with differently is an important first step towards creating a Just Culture in your organization, which will in turn encourage your staff to report their incidents. In my next column, I will use experiences from other sectors to share some practical steps for implementing a Just Culture in humanitarian organizations.