Patient SafetyUncategorizedWorkplace Management

Issues up close


It is well-established that healthcare is hazardous work. Nurses and other healthcare workers are at increased risk of physical harm from needlesticks, bloodborne pathogens, unsafe patient handling practices, physical abuse, and the effects of chronic fatigue. Emotional injury also is of concern, as many healthcare workers experience bullying, incivility, and verbal abuse.

When healthcare workers experience unsafe and unhealthy working conditions, patient safety also suffers. For instance, healthcare workers who have experienced sleep loss due to shiftwork and extended work hours are more likely to make medical errors. Healthcare workers who experience bullying and verbal abuse from their peers and superiors may be less engaged at work and more likely to make medication errors. Additionally, patients may be at an increased risk for falls and other injuries when a comprehensive safe patient handling and mobility program is not in place within an organization.

In ANA’s 2011 Health and Safety Survey, 63% of nurses reported that health and safety concerns influence their decisions about the kind of nursing work they do, 59% reported that these concerns affect their decision to continue to practice, and 40% responded that unsafe working conditions interfere with their ability to deliver quality nursing care. The majority of respondents felt safe in their current work environment, and 58% stated that their employers informed them about dangerous and unhealthy conditions. It is positive that these were majority responses, but it’s concerning that 40% of nurses selected “disagree” or “neutral” when responding to these statements. (See Opinions relating to the nursing work environment by clicking the PDf icon above.)

Culture of safety

While this information may be disconcerting, it is important to understand the ramifications of an unhealthy and unsafe work environment. The next step involves a widespread, proactive effort to achieve a culture of safety.

A culture of safety in health care includes the core values and behaviors that result from a collective, consistent, and sustained commitment by organizational leadership, managers, healthcare workers, and ancillary/support staff to emphasize safety over competing goals. Leaders can drive the culture of safety by demonstrating their own commitment, providing the resources to achieve the desired results, and ensuring that policies, themes, and behaviors related to safety become widely accepted practice.

A culture of safety in health care includes a fair and nonpunitive culture, as described in just culture principles, a process for right of refusal, a system for safe staffing, and open, collaborative, and congenial communication. The concept of a fair and just culture evolved from the work of behavioral, management, and clinical researchers who found that an organization’s response to errors influences the prevention of errors in the future. An organization practicing just culture recognizes that many circumstances leading to errors can be predicted. Additionally, it is recognized that skilled employees do make errors and should be encouraged to report them. Errors reported should be used to investigate root causes and correct related system issues. Within a just culture, healthcare workers are not held responsible for system issues they cannot control.

Creating joy and meaning through safety

The concept of a culture of safety is reiterated in the recent National Patient Safety Foundation (NPSF) report titled “Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care.” The report acknowledges that patient care brings joy and meaning to the lives of healthcare workers. However, without cultural norms that set the preconditions of physical and psychological safety, healthcare workers are less likely to be motivated and find meaning in their work. Consequences of this include the costs of employee burnout, lost productivity, turnover, and increased difficulty attracting new employees.

According to NPSF, the solution involves leadership support and a shared commitment among the entire workforce to express civility and respect, to be transparent in the reporting of errors and hazards, and for all to be a part of the problem-solving team. The seven strategies below are outlined in the report.

Recommendations from the National Patient Safety Foundation

Strategy 1: Develop and embody shared core values of mutual respect and civility, transparency and truth telling, safety of all workers and patients, and alignment and accountability from the boardroom through the front lines.

Strategy 2: Adopt the explicit aim to eliminate harm to the workforce and to patients.

Strategy 3: Commit to creating a high-reliability organization and demonstrate the discipline to achieve highly reliable performance. This will require creating a learning and improvement system and adopting evidence-based management skills for reliability.

Strategy 4: Create a learning and improvement system.

Strategy 5: Establish data capture, database, and performance metrics for accountability and improvement.

Strategy 6: Recognize and celebrate the work and accomplishments of the workforce, regularly and with high visibility.

Strategy 7: Support industry-wide research to design and conduct studies that will explore issues and conditions in health care that are harming our workforce and our patients.

Reprinted with permission from the National Patient Safety Foundation report “Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care”

Joint Commission monograph “Improving Patient and Worker Safety”

In its 2012 monograph titled “Improving Patient and Worker Safety,” The Joint Commission calls for “a serious, evidence-based approach to identify opportunities to improve the quality of the health care workplace, and in so doing, improve both the health of patients and health care workers.” The monograph includes examples of healthcare organization practices that have successfully addressed healthcare worker and patient safety, as well as strategies and tools that can be used to integrate safety activities.

Conditions needed to provide optimal care

Optimal patient care is safe, high-quality care. Healthcare workers cannot provide optimal care unless they have a healthy and safe work environment. Leaders within an organization must foster a culture of safety where health and safety are emphasized before all competing priorities.

ANA recognizes the inextricable link between healthcare worker safety and patient safety, and is committed to helping organizations achieve healthy work environments. Such resources as the new Safe Patient Handling and Mobility: Interprofessional National Standards provide strategies for protecting healthcare workers and patients while improving the quality of care across the care continuum. ANA offers a web course on understanding shiftwork sleep disorder, as well as educational materials to help prevent bullying in the workplace. To access these and other healthy work environment resources, visit

Jaime Murphy Dawson is a senior policy analyst in ANA’s Department for Health, Safety, and Wellness.

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