Theoretical underpinnings

In this review, 58 articles used theory to guide their studies or proposed theories to move research in safety culture forward, and the remainder of studies did not indicate their epistemological or theoretical roots. Within these studies, 32 different theories emerged (online appendix 1 contains a list of theories by article), and some studies employed more than one theory. The five most frequently adopted theories are summarised in table 1.

Defining safety culture

Common terminology included safety culture, culture of safety or safety climate. Results indicate considerable variation in the use of terms and definitions. For example, there is an ongoing debate about whether safety culture is inherently different from the concept of safety climate. To complicate the situation, the two terms are often defined the same and are used interchangeably within publications. One researcher suggests that, ‘safety culture has the definitional precision of a cloud.’3 Most researchers prefer the term safety culture (n=42), others adopted the term safety climate (n=8), and still some studies took a more holistic approach defining both terms (n=11) (online appendix 1). An overwhelming majority of studies used, but did not define, either term (n=82). The most commonly (n=17) used definition of safety culture was as follows:

The product of individual and group values, attitudes, competencies and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organisation's health and safety programmes. Organisations with a positive safety culture are characterised by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measure.8

Meanwhile, safety climate was commonly defined as, ‘surface features of the safety culture from attitudes and perceptions of individuals at a given point in time’ or ‘the measurable components of safety culture.’9 10

Dimensions of safety culture

Much like the disagreement in the definition of safety culture as a concept, this variance extends into the dimensions comprising a positive safety culture. Since researchers have yet to reach consensus on the dimensions that comprise safety culture, several different combinations of dimensions exist. Dimensions often arose from factor analysis of quantitative safety culture questionnaires, and these combinations of dimensions subsequently became a way to conceptualise safety culture. One hundred and thirteen of the reviewed articles provided dimensions (online appendix 1), and the most frequently cited dimensions included:

• leadership commitment to safety;

• open communication founded on trust;

• organisational learning;

• a non-punitive approach to adverse event reporting and analysis;

• teamwork; and

• shared belief in the importance of safety.

Measuring safety culture

Safety culture in healthcare settings is typically assessed through quantitative questionnaires based upon any number and combination of the dimensions. A previously published study assessed the psychometric properties of available tools.11 These tools vary in the number of dimensions they measure (three to 12), length (from 30 to 79 items) and reliability (α ranging from 0.63 to 0.86).11 This review identified 12 different survey tools, as listed in online appendix 1. The following four tools were the most frequently cited:

• Agency for Healthcare Research and Quality (AHRQ)'s Hospital Survey on Patient Safety Culture12;

• Safety Attitudes Questionnaire13;

• Patient Safety Culture in Healthcare Organizations Survey (PSCHO)14;

• Modified Stanford Patient Safety Culture Survey Instrument (MSI).15

While regulatory and accreditation bodies have been quick to adopt and promote the use of these tools, one researcher cautions that strong evidence of psychometric rigour has not yet been published for the measurement of healthcare safety culture.16 Conversely, among the articles reviewed, 14 utilised qualitative methods to collect data on safety culture (online appendix 1). Of these, seven used semistructured interviews; two employed focus groups, and two used observations.

A few studies adapted Westrum's industry-focused typology of organisational cultures into varying models of cultural maturity for healthcare settings.4 According to Westrum, five phases of safety culture maturity were characterised to be:

• Pathological: who cares about safety as long as we are not caught?

• Reactive: safety is important—we do a lot every time we have an accident.

• Calculative: we have systems in place to manage all hazards.

• Proactive: we try to anticipate safety problems before they arise.

• Generative: safety is how we do business around here.4

Three studies made use of Westrum's model by adapting it to fit the healthcare context by developing new tools, such as the Manchester Patient Safety Framework (MaPSaF) and the Patient Safety Culture Improvement Tool.17–19 These tools can be used in a collaborative manner to diagnose culture maturity and provide a framework for safety improvement.

While surveys can provide an understanding of staff attitudes and beliefs, it was recommended by several authors to supplement these quantitative data with richer qualitative data through interviews, focus groups and observations to gain a better sense of the underlying culture.6 20 21 Employing ethnographic methods of observation and interviews were also suggested to examine the validity of surveys.20 One study suggested that in-depth, long-term study using qualitative methods longitudinally is the only way to gain a deep understanding of culture.21

Improving safety culture via interventions

Despite the overwhelming rise in healthcare safety culture assessment, description alone cannot improve the safety culture of an organisation. Instead, improving safety culture was most frequently accomplished by implementing any number of interventions, often targeting one or more dimensions of safety culture at a time. Twenty-one studies reported or proposed the improvement of safety culture by implementing multifaceted interventions (online appendix 1). One study suggested that the first step was to assess the current status, normally accomplished via surveys.22 The following stepwise solution to improving reliability was proposed by one group of researchers: (1) assess culture of safety; (2) provide safety science education; (3) identify safety concerns; (4) establish senior leadership partnerships with units; (5) learn from one safety defect per month; and (6) reassess culture.23

Several interventions to improve safety exist, and some are more prevalent than others. Team training, patient safety team creation, leadership ‘walkarounds’ and patient safety education programmes were the most frequently cited interventions; however, other less frequently implemented interventions, such as safety audits, event reporting and analysis systems, and the dissemination of patient safety-related information to staff and patients, were also reported. All articles implementing or proposing interventions are itemised in online appendix 1. None of the articles reviewed assessed the effectiveness of interventions.