STOP STICKS CAMPAIGN

Safety Culture

There are many prevention strategies that health care organizations can use to reduce occupational sharps injuries. While some of these strategies focus on specific individual or job- and task-level improvements, such as implementing appropriate safety devices or using safe work practices, an organizational perspective on safety is essential. Maintaining a safety culture will help protect patients, workers, and others in the health care environment.

Safety culture concepts

Culture refers to factors that influence overall attitudes and behavior in organizations. Leadership and management style, institution mission and goals, and organization of work processes are aspects of culture. Culture provides the background against which day-to-day tasks are performed and has been shown to be strongly associated with worker perceptions of job characteristics and organizational functioning.

A safety culture reflects the shared commitment of management and employees toward ensuring the safety of the work environment. Whether or not employees perceive the presence of a safety culture is based on several factors including specific actions taken by management to improve safety:

• Openly supporting safety culture through supply of resources
• Engaging worker participation in safety planning
• Having written safety guidelines and policies
• Making available appropriate safety devices and protective equipment
• Influencing work-group norms regarding acceptable safety practices
• Introducing workers to a safety culture when they are first hired

All of these factors serve to communicate to workers the organization's commitment to safety.

The concept of safety culture is not the same as environmental safety, occupational health and safety, or patient safety. Those are programs with specific goals that often have associated regulatory requirements. A safety culture permeates all aspects of the work environment and is reflected in a level of awareness and accountability for safety on the part of every individual in an organization.

The value of safety culture to health care organizations

Most of our knowledge about safety culture comes from manufacturing and heavy industry work settings where it was first studied. This research tried to identify the critical determinants of successful safety programs. Determinants that were consistently identified included management's involvement in safety programs, high status and rank for safety officers, strong safety training and safety communications programs, orderly plant operations, and an emphasis on recognizing individual safety performance rather than a reliance on punitive measures.

Some industrial sectors have found that having a strong safety culture is positively associated with productivity, cost, product quality, and employee satisfaction. Organizations with strong safety cultures consistently report fewer injuries than organizations with weak safety cultures, not only because the workplace has well developed and effective safety programs, but also because management, through these programs, sends "cues" to employees about the organization's commitment to safety.

While the idea of systematically adopting a safety culture is relatively new for the health care industry, there are some published studies of its effects in some health care organizations. Safety culture has been linked with both employee compliance with safe work practices and reduced exposure to blood and other body fluids, including reductions in sharps-related injuries.

Safety culture is also related to patient care and safety. The Institute of Medicine's widely cited report, To Err Is Human, disclosed that medical errors represent one of the nation's leading causes of death and injury, with estimates of 44,000 to 98,000 deaths in U.S. hospitals per year. Although the causes of medical error are numerous, the pivotal role of safety culture in preventing such mishaps was repeatedly emphasized in the report.

Strategies for establishing safety culture in a sharps injury prevention program

Components

Creating or improving an organization's safety culture means finding ways to influence employee attitudes and behaviors. It also means reducing environmental hazards. Specifically:

• Ensure that there is a commitment to safety at all levels of the organization, beginning with management.
• Involve employees in planning and implementing activities that promote a safe health care environment.
• Identify and remove sharps injury hazards in the work environment.
• Develop communication and feedback links to increase safety awareness.
• Promote individual accountability.

1: Ensure organizational commitment

To communicate an organization's commitment to safety:

• Use specific strategies for top management and directors.
• Incorporate statements related to safety (e.g., zero tolerance for unsafe conditions and practices) in an organization's mission, vision, values, goals, and objectives.
• Give high priority and visibility to committees that deal with safety (e.g., occupational health, infection control, quality assurance, pharmacy, and therapeutics) and ensure direct management involvement in evaluating committee processes and impact.
• Require action plans for integrating safety interventions into ongoing planning processes in an organization. The action plan for improving the safety culture for sharps injury prevention can be one piece in an overall safety culture initiative.

Role modeling safe attitudes and practices is an indirect way that management communicates commitment to safety. Health care leaders send important messages to subordinates when they show regard for how sharps devices are handled, take steps to protect coworkers from sharps injuries, and properly dispose of sharps. Similarly, managers who address sharps hazards as soon as they are observed and discuss safety concerns with their staff on a regular basis reflect the organization's commitment to safety and build safety awareness among staff.

2: Involve workers in planning and implementing activities that promote a safe health care environment

Involve workers from many areas and disciplines in planning and carrying out activities that promote safety culture. Workers who participate on committees or teams created to work on safety issues serve as conduits of information from and to their various work sites and legitimize safety in the eyes of their peers.

3: Identify and remove sharps injury hazards in the work environment

Create a nonpunitive environment for reporting sharps injuries and injury hazards. Health care personnel who know that hazards can be discussed with management in a way that does not result in blaming of employees are more likely to be alert for hazards and report them. Hazards must be known to be eliminated.

Health care organizations also can actively look for sharps injury hazards by encouraging the reporting of "near misses" and by performing observational rounds in various areas in the health care environment. Once identified, hazards should be investigated promptly to find root causes, contributing factors, and preventive actions.

4: Develop feedback systems to increase safety awareness

Provide information on all sharps injury prevention efforts in the organization. Use newsletter articles, memos, e-mail, bulletin boards, or any other communication channel that gets used in your organization. Incorporate feedback mechanisms to gather reactions and more information on hazard investigations, ongoing problems with sharps injuries, and prevention improvements. Create brochures and posters to enhance safety awareness. These are all ways to communicate that safety is valued in the organization.

5: Promote individual accountability

Promoting individual accountability for safety communicates a strong message about the organization's commitment to safety. To be an effective tool, accountability must be expected from all levels in the organization. There are many ways an organization can promote individual accountability for safe practices in general and sharps injury prevention in particular. Incorporate an assessment of safety compliance practices in all annual performance evaluations. For managers and supervisors, evaluations might include consideration of methods used to communicate safety concerns to subordinates, collectively and individually. An organization also might consider having staff sign a pledge to promote a safe health care environment. This could be incorporated into hiring procedures or as part of an organization-wide safety campaign.

Measuring improvements in safety culture

Four sources of data can be analyzed to assess changes in safety culture related to sharps injury prevention:

1. Responses from staff surveys on perceptions of the safety climate in the organization
2. Hazard reports
3. Observational hazard assessments
4. Sharps injury reports

While building and maintaining a strong safety culture is a common recommendation for the prevention of injury and illness across many sectors of industry, safety climate is considered to be a "snapshot" of an organization's current state of safety, measured by questionnaire surveys of employees' perceptions, attitudes, and beliefs about risk and safety. Safety culture is a more enduring trait which reflects an organization's fundamental values, norms, assumptions and expectations. Thus, safety climate is a manifestation of safety culture.

Use this survey before and after the STOP STICKS campaign to measure changes in your organization's safety climate.

As changes in safety culture occur, any or all of these measures may reflect the change. The more measures you can examine, the better your assessment will be. For example, an increase in sharps injury reports may (at least initially) reflect a greater openness and acceptance of injury reporting in your organization.

As problems are addressed and corrected, there also should be a decrease in specific hazards previously identified in hazard reports or observational assessments and fewer injuries due to inappropriately discarded sharps, collisions with other staff, and other injuries that could be prevented through safer work practices. If this is not the case, the sharps injury prevention leadership team should reassess the strategies used to build and sustain a safety culture and revise its performance improvement action plan accordingly.

Content adapted from the CDC Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention Program by:
Linda Chiarello, RN
Centers for Disease Control and Prevention
National Center for Infectious Diseases