The Field Guide › Article
Examines why Just Culture — first developed in James Reason's 1997 Managing the Risks of Organisational Accidents, extended to healthcare by David Marx, and deepened by Sidney Dekker — so often fails to 'stick' in practice. 'Just' means justice, not 'only', and crucially it aligns with restorative rather than retributive justice: Dekker frames the choice as backward-looking and retributive versus forward-looking and change-oriented. A just culture balances accountability with learning, treating people with fairness and compassion on the premise that humans will inevitably make mistakes and that punitive responses obstruct improvement. The article threads in local rationality (people act in ways that seem rational given their context, and the opposite stance is the fundamental attribution error), the work-as-imagined vs work-as-done gap, blametropism, and the restorative reframing of accountability as 'giving an account' rather than assigning fault — centring who was harmed, what they need, and whose obligation it is to meet those needs (including the 'second victims', the staff involved). The Elaine Bromiley case anchors the argument. The core claim: Just Culture is frequently imposed as mechanics (reporting systems, restorative meetings, non-punitive investigations) without the foundational culture, so teams revert to punitive habits. Drawing on the four lenses of change (values, behaviours, practices, systems/structures) and the NUMMI story, it argues psychological safety is the substrate in which a Just Culture thrives — without it, the effort stays superficial. Wider legal, regulatory and media pressures (headline-driven scapegoating, punitive inquests) routinely undermine even genuine internal efforts.