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Overview and Summary: Creating a Culture of Safety: The Next Steps

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Mary Sitterding, MSN, CNS, CNRN

Citation: Sitterding, M., (September 30, 2011) "Overview and Summary: Creating a Culture of Safety: The Next Steps" OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 3, Overview and Summary.

DOI: 10.3912/OJIN.Vol16No03ManOS

Patient care errors continue to threaten patient safety and erode trust among the public we are privileged to serve. Recent studies have suggested the number and the percentage of adverse events has actually been grossly underestimated. Classen and colleagues (Claussen et al., 2011; Resar, Simmonds, & Haraden, 2006) found that estimates of adverse events among critical care patients indicate 11.3 adverse events/100 Intensive Care Unit days and 2.04 adverse events/patient; these estimates may be as much as ten times greater than previously measured and reported. Sharek and colleagues (2006) discovered an incidence of 74 adverse events/100 admissions in a neonatal critical care unit, and suggested that 56% of all adverse events are preventable. These recent statistics are a call to action for nurses to better understand the culture of patient safety and to identify with greater clarity the unique contribution nurses can make in decreasing adverse events, regardless of whether we work in practice, academe, or policy arenas. Radical change is essential. We need change that dives deeper, away from the tip of the iceberg and toward the core.

The articles in this OJIN topic address ways in which nursing can dive deeper into the ‘core of the iceberg.’ As a collection these articles describe how the Magnet® nursing excellence framework enables a culture of patient safety; present a new model that describes nursing practice within a culture of safety; explain how nurses can practice within a culture of safety; provide insight about essential roles needed to support a culture of safety; and offer considerations for preparing the next generation of nurses to serve within a culture of safety.

The relationship between nursing excellence and a culture of patient safety is illustrated by Swanson and Tidwell as they detail their Magnet Journey. These authors describe each Magnet Component (ANCC, 2008) and provide explicit examples of structures, processes, and outcomes in alignment with a culture of patient safety. Approaches that enhance effective communication through intentional nurse-physician collaboratives are described and cited as factors contributing to both Magnet status and a culture of patient safety. The authors clearly illustrate how the Magnet Recognition Program provides an exemplary framework for nursing excellence, one that is in direct alignment with a culture of patient and workplace safety.

Morath introduces readers to the Dynamic Systems Model (DSM), a model that describes the interaction between individual benefit and system benefit and illustrates the impact of this interaction on the culture of patient safety. One underlying assumption of the DSM is that as individual benefit increases, the system benefit decreases. Morath explains how the individual nurse and the system work within an envelope of boundaries that include operations/workload, financial, and safety factors.The model is used to describe the potential for migration into unsafe practices, for example through work-arounds that decrease task time yet increase the potential for error, and to suggest reasons for failure to recognize subtle warning signs.

Sammer and James present the nursing unit leader role through a fictional lens describing what happened in a hospital lacking a culture of patient safety and what an optimal culture of safety environment could look like in an exemplary culture of patient safety. The authors masterfully narrate the story of a fictional patient within a fictional facility with a fictional team to illustrate the link between elements of the story and the subcultures of patient safety, as descried by Sammer, Lykens, Singh, Mains, and Lackan (2010). Paramount to the practice setting is academic preparation for the next generation of nurses to recognize and to practice within a culture of safety.

Reid and Dennison describe the role and essential functions of the Clinical Nurse Leader (CNL)® illustrating the alignment between the academic preparation of the CNL and the competencies CLNs demonstrate in a variety of settings. The authors present the essential functions of the CNL that enhance safety at the point of care. Student exemplars display the alignment between the contributions of the CNL student and the enhancement of a culture of patient safety. Reid and Dennison conclude by highlighting the power that CNLs have for building continuing coalitions of safety.

Barnsteiner makes the case for integrating the Quality and Safety Education in Nursing (QSEN) competencies into the curriculum through the use of classroom, simulation, and clinical activities. She explains the value of using a developmental approach in teaching these competencies and gives examples of numerous classroom activities and assignments that can be used to teach students how to establish and maintain a culture of safety. Barnsteiner also notes the need to integrate the QSEN competencies into existing and emerging nurse residency programs.

Roles, educational preparation, frameworks for excellence, and models that describe, explain, and/or predict a culture of safety position us to answer the call for the radical change that is required in view of the evidence cited earlier in this Overview and Summary. Each of the articles in this topic link a culture of patient safety with the need for hazard recognition and containment, regardless of whether the article is describing a particular role, academic preparation, framework, or model. Vogus, Sutcliff, and Weick (2010) would suggest that the current practice environment or culture does not provide the structures needed for consistent translation and enactment of evidence-based, safety-hazard recognition and guidelines into meaningful practice. Beyond the integration of established best practice, what do we really understand about factors that enable threat recognition?

Hospitals and other healthcare delivery organizations have looked to other organizations that consistently achieve safe and high quality performance despite operating under difficult conditions. These nearly error-free, high-reliability organizations (HROs) include naval aircraft carriers, nuclear power plant control rooms, and air traffic control. The highly reliable performance of HROs is posited to result from processes of mindful organizing (noticing the unexpected) (Weick & Sutcliffe, 2007).

At the level of the individual nurse, Benner, Hooper-Kyriakidis, and Stannard (2011) have described the need for nurses to be able to recognize and mitigate hazards. They have suggested that clinical forethought is about anticipating and preventing potential problems. They have described attributes of clinical forethought as including: “future think; forethought about specific diagnoses and injuries; anticipation of crises, risks, and vulnerabilities for particular patients; and seeing the unexpected” (Benner et al., p. 71). What remains relatively unexplored is how one prepares, leads, and evaluates an individual’s or team’s capacity to mindfully organize, or anticipate and contain, hazards within a culture of patient safety. The articles in this topic provide initial guidance and insight that informs considerations specific to essential practice roles and the educational curriculum, as well as frameworks and models that can contribute to a culture of patient safety.

The authors for this topic answer the call for a radical change that will enable us to dive deeper toward to the core, away from the tip of the iceberg. Critically examining and aligning academic preparation and roles with the culture of patient safety, adopting a framework for nursing excellence that clearly integrates the subcultures of patient safety, and exploring models that describe and/or predict the migration of nursing to at-risk and unsafe practice clearly position us to better understand and develop a culture of patient safety. We can now do that with the depth and wisdom that we have and that is necessary to meet the demands of those we are privileged to serve. I encourage each reader to review these articles offering ideas for education, practice, and policy that can help us achieve and sustain cultures of safety. Nursing is uniquely positioned to contribute to the interdisciplinary education, practice, and policy-table-generating and testing solutions intended to create and sustain excellence in patient care safety.


Mary Sitterding, MSN, CNS, CNRN

Ms. Sitterding is Director, Nursing Research and Professional Practice, at Indiana University Health in Indianapolis, IN. She is recognized for her expertise in patient safety, quality, complex adaptive systems, change management, diffusion of innovation, and professional nursing practice. She has recently been appointed to serve a second term on the American Organization of Nurse Executives Patient Safety and Quality Committee. She also serves as an Appraiser for the Magnet Recognition Program of the American Nurses Credentialing Center. Ms. Sitterding received her MSN at the Indiana University School of Nursing where she is currently completing her doctoral dissertation examining the cognitive and relational mechanisms influencing nursing work complexity, RN stacking, and sensemaking.


American Nurses Credentialing Center (2008). Magnet recognition program: Application manual. Washington, DC: American Nurses Publishing.

Benner, P., Hooper-Kyriakidis, P., & Stannard, D. (2011). Clinical wisdom and interventions in acute and critical care. A thinking-in-action approach. (2nd ed.). New York, NY: Springer Publishing Company. Retrieved September 30, 2011 from

Classen, D., Resar, R., Griffin, F., Federico, F., Frankel, T., Kimmel, N.,…James, B. (2011). Global trigger tool shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs 30(4), 581–589.

Resar, R.K., Simmonds, T., & Haraden, C.R. (2006). A trigger tool to identify adverse events in the intensive care unit.  Joint Commission Journal on Quality and Patient Safety, 32(10), 585–590.

Sammer, C., Lykens, K., Singh, K., Mains, D., & Lackan, N. (2010). What is patient safety culture? A review of the literature. Journal of Nursing Scholarship, 42(2), 156-165.

Sharek, P.J., Horbar, J.D., Mason, W., Bisarya, H., Thur, M., Suresh, G.,...Classen, D. (2006). Adverse events in the neonatal intensive care unit: Development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs. Pediatrics, 118(4), 1332–1340.

Vogus, T., Sutcliff, K., & Weick, K.E. (2010). Doing no harm: Enabling, enacting, and elaborating a culture of safety in health care. Academy of Management Perspectives, 24(4), 60–77.

Weick, K. E., & Sutcliffe, K. M. (2007). Managing the unexpected: Resilient performance in an age of uncertainty, 2nd Edition. San Francisco, CA: Jossey-Bass.

© 2011 OJIN: The Online Journal of Issues in Nursing 
Article published September 30, 2011