Figure 10.1 How necessary additional safety procedures reduce the scope of action required to perform tasks effectively
(from Reason 1998, with permission).
Organisational Culture Affects Rule Violation Frequency
Clinicians break the rules for a variety of reasons. Some, as described above, are a direct result of the organisation itself, but other factors can lead to similar outcomes. Except for exceptional circumstances, there is a balance to be considered, as shown in Table 10.1. Although it is the individual who decides whether or not to break the rule, it is the culture of the organisation that influences what action will be taken. For example, an organisation that does not impose sanctions for rule violation will actually promote such violations.
Table 10.1 Summarising the violation balance sheet
(from Reason 2008, with permission)
| Perceived benefits | Perceived costs |
| Easier way of working | Causes accident |
| Saves time | Injury to self or others |
| More exciting | Damage to assets |
| Gets the job done | Costly to repair/resolve |
| Shows skill | Sanctions/punishment |
| Meets a deadline | Loss of job/promotion |
| Looks macho | Disapproval of friends |
Practical Strategies and Application
Leadership
Leadership and teamworking are covered elsewhere in this book, but in cultural terms, it is essential that those in clinical leadership positions model good safety behaviours. If senior clinicians regularly violate procedures, take short cuts or ‘bend the rules’, then junior clinicians will copy such behaviour. Senior clinicians who are aware of their own violation of rules should consider the validity of the rules themselves and either comply with them or change them. Senior clinicians and managers must lead by example, with a visible commitment to safety. If not, then safety initiatives will be undermined.
Staff Engagement
While leaders, managers and senior clinicians can influence an organisation by directing individuals how to change their work behaviour, they will only succeed if they also engage with staff to influence their values. Top-down management styles that dictate working behaviours without involvement of the staff themselves will fail, as without input, staff will not feel ownership of the behaviour. While there is no doubt that clinicians learn and adopt safety behaviours partly through procedures, the adherence to these procedures is influenced through a socialisation process that takes place when new members join the organisation. In education, such learning is often described as the ‘hidden curriculum’. It is those parts of the job that, although not documented, are essential for successful performance. In most healthcare settings, new starters/juniors learn such values through the observation of seniors. They learn the culture through observation and discussion, through feedback and criticism. Working with and influencing new members of an organisation is therefore an effective way of influencing culture, but only if they are culturally socialised (mentored, supervised) by a senior in the organisation who holds and exhibits positive cultural attributes. The selection of such individuals is a key task for managers.
Assessing an Organisational Culture
It is important to consider the influence of the culture of an organisation when investigating incidents or when considering new safety initiatives. In many cases, it is easier to observe a safety culture from the perspective of a newcomer/observer than from within the organisation. Organisations with a poor safety culture (Health & Safety Executive 2011) are characterised by:
- widespread or routine procedural violations
- failure to comply with departmental or Trust safety procedures (e.g. the paradox of low or no patient safety incident reports submitted)
- management decisions that put performance targets before patient safety
Summary
The safety culture of an organisation is highly influential in the adoption, ownership and persistence of safety procedures. All clinicians have a role in developing an organisational culture that promotes and monitors safety.
Personal Exercises
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