Cultural influences on workplace safety: An example of hospital workers’ adoption of patient lifting devices

Abstract

Aims

A sociological and anthropological view of culture was used to investigate how work culture, independent of “safety culture”, may affect safety in the workplace. We explored how work cultures of nurses and physical/occupational therapists (PT/OTs) in two acute care hospitals are related to the adoption of patient lifting devices.

Methods

Focus groups were conducted between 2006 and 2009, seven with nurse staff (n = 39) and two with PT/OT staff (n = 17), to explore issues concerning a Minimal Manual Lift Environment policy, initiated in 2004, and subsequent use of patient lift equipment. Audio recordings of the sessions were transcribed; text data were analyzed using N6-QSR. Cultural facilitators and barriers to the adoption of patient lift equipment were examined.

Results

Data revealed cultural similarities and differences between these healthcare professions. Both displayed a “patient first” approach to care-giving which may promote lift device use for patients’ benefits, not necessarily for staff safety. Also, the implied purpose of patient lifting devices clashes with the nurses’ cultural emphasis on compassion, and with PT/OTs’ cultural emphasis on independence except when use increases patients’ independence.

Conclusions

Cultural expressions regarding the nature of care-giving among healthcare professionals may affect the propensity to adopt safety measures in complex ways. The workers’ understanding of the purpose of their work, and acceptable means of conducting it, should be understood before implementing safety interventions. The utilization of lift assist teams, who are not socialized into the cultures of nursing or PT/OT, may be one means of circumventing cultural barriers to lift equipment use.

Introduction

The terms “safety culture” and “safety climate” have become prevalent in studies of work-related injury and musculoskeletal disorders. Although they may represent different things to various researchers (Guldenmund, 2000, Hale, 2000), these concepts are often directed at elements of culture that address safety matters explicitly. For example, according to Guldenmund (2007), the goal of safety culture (and safety climate) is to “determin[e] the importance of safety within an organization” (p. 723). We argue, however, that the culture in an organization may affect safety without explicitly being about safety at all.

One manner in which culture may be highly relevant for safety is that it is used in part to guide the norms of acceptable behaviors and work conditions which may be related to safety, even though the culture does not explicitly address safety or risk. As a means of making sense of the world (Geertz, 1973), culture among workers provides a framework within which aspects of the workplace will be understood. Culture may affect many decisions concerning how work is to be done and some of these may affect work-related injury risk. For example, classic sociological studies of piecework incentive systems have shown that work groups may generate “shop floor” norms regarding an acceptable rate of work output (Homans, 1992, Roethlisberger et al., 1939, Roy, 1953). Such norms may be based, in part, on culturally determined assessments of fairness (Homans, 1992) without any consideration of safety. Nonetheless safety may be affected when the rate of work output (i.e., work pace or intensity) and risk of injury are related.

The predominant aspect of the nursing profession around which its culture is based is caring for patients (Chambliss, 1996, Leininger, 1984, Reverby, 1987); the culture of nursing has been referred to explicitly as the “culture of caring” (Leininger, 1984). This cultural trait exists, in some form, in other healthcare occupations as well, for example, among nurse aides (Anderson et al., 2005) and among surgeons (Bosk, 1979). While some aspects of the culture of caring span healthcare occupations, others may vary by occupation (e.g., nursing vs. surgery) and by the local setting within an institution (e.g., intensive care unit vs. emergency department in a single hospital). The view of culture used here, therefore, acknowledges both broad and local sources of culture¹ and cultural variation. In this study, the cultural interpretations of care-giving among nursing and PT/OT staff in two acute care hospitals were investigated. We identified characteristics of the culture of caring within each occupational group and explored how these cultural traits affected how patient lifting devices, provided as part of a newly implemented safety policy, were defined within each group.

What we are concerned with here is most closely associated with what has been called “occupational culture” (Schein, 1996) and its potential impact on safety, apart from that of “safety culture”. In this study, we explore how culture among nurses and physical and occupational therapists working in the acute care hospital setting may affect safety and how the meaning associated with care-giving among nursing and PT/OT staff may include cultural biases towards the adoption of patient lifting devices into patient care routines. In Hale’s words, we explored “cultural influences on safety and not safety culture” (Hale, 2000, p. 5).

This study was part of an ongoing evaluation of a Minimal Manual Lift Environment (MMLE) policy implemented in a tertiary care hospital and an affiliated community hospital in the Southeastern United States to provide for the safety of patients and staff during all patient-handling tasks. Details of the MMLE intervention are described elsewhere (Schoenfisch et al., 2011). Briefly, the medical center and community hospital in this study implemented the MMLE policy on inpatient nursing units in October 2004 and January 2005, respectively. Lift equipment and transfer devices were purchased for inpatient units. Both facilities use a train-the-trainer approach to instruct the staff in proper lift use; unit “coaches” are trained to teach staff about safe use of the equipment, and the MMLE policy, on an ongoing basis. Ergonomists from the university Occupational and Environmental Safety Office (OESO), who had been working with inpatient nursing staff surrounding patient-handling concerns several years prior to the intervention, were involved in coordinating and implementing efforts to support the MMLE policy, coach/staff training, and use of the lift equipment. Quantitative results of the broader evaluation (Schoenfisch et al., 2011) suggested limited and variable adoption of the patient lifting devices had occurred over the 5 year period following their introduction on nursing and PT/OT units. Using qualitative data from focus groups, the purpose of this analysis was to explore the possible role played by the culture in the limited adoption of the patient lift equipment.