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The Change Challenge: Interventions to Build a Culture of Safety
Part 3 of a four-part series on 'Culture' in patient safety
Satyan Chari
August 15, 2024
Photo by Kai Pilger on Unsplash
There are two distinctive views of culture. The first is optimistic about the potential for purposive cultural management, seeing culture as something that an organisation has— an attribute that can be assessed and manipulated to improve care.
By contrast, the second view is more concerned with securing insights about organisational dynamics, without focusing on whether they can be manipulated. It sees organisational culture as something the organisation simply is—an account of local dynamics not readily separable from the organisational here-and-now.
Introduction
Welcome to the third instalment of a four-part series on culture and patient safety. In the previous issue of The Human Stream, “Accounting for Safety Culture”, we looked at how safety culture has come to be defined and measured in healthcare.
In part 3 of this exploration, we look at some of the main ways in which healthcare organisations have sought to influence culture (or some aspect of it) to enhance safety.
The final issue in this series will be in the form of a pragmatic practice guide for leaders and practitioners attempting to navigate questions of culture in patient safety.
(Culture)….."has the definitional precision of a cloud.”
Measurement has been the cornerstone of safety culture work in healthcare just as it has been for most aspects of the global patient safety endeavour. A 2017 review of safety culture measurement tools by researchers from Macquarie University3 identified 46 different tools that have been developed solely for the assessment of safety culture and its dimensions in healthcare. Despite the plethora of options, the authors commented “no single tool captured the complexities of safety culture”.
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Several commentators, particularly those drawing from the sociological and safety science traditions, critique what they view to be a premature rush to formalise tools for measuring safety culture, despite a number of unresolved questions that persist at the most fundamental level: what it is3 , how it relates to other dimensions of organisational culture (or to its purported sub-components like reporting cultures, or just/no-blame cultures), the validity of the assumed causal links between ‘safety culture’ and safety practices, the underpinning mechanisms of action (MoA), and the legitimacy of efforts to try to shift ‘culture’ through formal interventions4 .
As we saw in the last issue, some experts even suggest a move away from the concept entirely, in light of its gradual evolution into a non-specific umbrella term.
Intervention trials aimed at enhancing safety culture
Given the increasing perception that cultural shortcomings underpin many problems in healthcare today, it is not surprising that the body of intervention research aimed at improving safety culture within healthcare is growing rapidly5 .
A 2013 systematic review6 included 21 studies on the efficacy of strategies to shift patient safety culture (or safety climate more specifically) including one randomised controlled trial. Morello and colleagues identified a diverse range of strategies in the trials they included, from leadership walk rounds, structured educational interventions, team-based strategies, simulation-based training programs, multi-dimensional unit-based programs and multi-component organisational interventions. The interventions were deployed at different scales (unit, departmental and whole organisations) and tested using a range of research designs.
While some of the interventions were suggestive of positive effects on at least one or two sub-domains of safety climate tools, the researchers concluded that there was little evidence of definitive impact on patient safety climate scores. They also recognised considerable heterogeneity in what constitutes a bona fide safety culture intervention.
Much more can be said about the specific interventions we find in the literature, and the implicit assumptions behind each. However, despite differences on that level, most intervention research on this topic tend to align with the “first” view described in quote at the start of this article. They generally regard ‘safety culture’ as something organisation possess and amenable to purposeful manipulation.
Photo by Salah Ait Mokhtar on Unsplash
This line of research also typically approaches safety culture as a “black box”, revealing much in common with the philosophical traditions of behaviourism and positivism - where the emphasis is more on inputs (in our case interventions), and outputs, that is, changes in objective measures or observable behaviour, than on the internal (or unobservable) mechanisms that bring about such changes.
While current evidence for these types of interventions is not compelling, the evidence base continues to swell. In time, updated compilations of the evidence7 could change the picture considerably. Yet, even if we could eventually prove causal links between specific interventions and positive shifts in safety climate surveys, we would still need to decipher how any of this translates into positive safety behaviour in real-world settings.
For that, it might help to look inside the black box.