deGruyter-Patient Safety - A Psychological Perspective

Hannes Zacher
Patient Safety – A Psychological Perspective

Patient Safety
Edited by
Oswald Sonntag and Mario Plebani
Volume 8
Hannes Zacher
Patient Safety –
A Psychological
Perspective
DE GRUYTER
Author
Dr. Hannes Zacher
Department of Organizational Psychology
Faculty of Behavioral and Social Sciences
University of Groningen
Grote Kruisstraat 2/1
9712TS Groningen, The Netherlands
The book has 21 figures and 4 tables.
ISBN 978-3-11-028173-6
e-ISBN 978-3-11-028192-7
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Preface
The purpose of this book is to explore the important and complex topic of patient
safety from a psychological perspective. Psychology is a science and a profession
that aims to understand, predict, and possibly change people’s experiences
and behaviors. Psychology also investigates the individual, interpersonal, and
contextual factors that influence people’s experiences and behaviors, as well as
the consequences of certain experiences and behaviors for individuals, teams, and
organizations. The main premise of this book is that patient safety and quality of
care are desirable outcomes of the interplay between health care professionals’ and
patients’ characteristics, experiences, and behaviors, as well as structural and social
factors of the healthcare context. Taking a multilevel systems approach, this book
addresses individual characteristics and processes, interpersonal and team factors,
and organizational characteristics that impact on those experiences and behaviors
of healthcare professionals and patients that are relevant to patient safety and the
quality of care.
I wrote this book for healthcare and clinical professionals, patients, practitioners
working in and providing support for healthcare teams and organizations, academics
in a variety of clinical fields such as medicine, dentistry, health and rehabilitation
sciences, nursing and midwifery, pharmacy, and psychology. By reading this book, I
trust that readers will appreciate the topic of patient safety in a novel and useful way,
and gain valuable insights for their interactions with (other) healthcare professionals,
for their everyday work with patients, and for planning and designing structured
interventions that aim to reduce medical errors and increase patient safety and the
quality of care.
As an organizational psychologist working in academia, I am interested in
developing theories and hypotheses based on observations in applied settings,
in empirically testing my theories and hypotheses in these settings, and in using
evidence-based principles to help improve organizational practice. I was enthusiastic
when the editors of this book series asked me to write a book on patient safety,
because this topic lends itself well to a systematic and thorough examination from
a psychological perspective. The healthcare context offers abundant opportunities
to develop and test psychological theories, and psychological theories, concepts,
methods, and empirical findings can be used fruitfully to understand, predict, and
also change experiences and behaviors in this context.
This book was written at the University of Queensland in Brisbane, Australia,
where I worked as a lecturer and research fellow in organizational psychology
between July 2010 and December 2013. Since then, I have started a new position as
associate professor in organizational psychology at the University of Groningen in the
Netherlands. The School of Psychology at the University of Queensland provided me
with the autonomy and support needed to write this book, and I am thankful for the
vi Preface
time I spent in this fabulous intellectual powerhouse down under. I am also grateful
to Brenda Hughes and Lauren Kramer for their help with literature search and proof-
reading. Last but not least, I thank my family for their support and for the wonderful
times we spend together.
Brisbane, September 2013

Hannes Zacher
Table of contents
Preface v
1 Introduction 1
1.1 Purpose of this book 1
1.2 A multilevel framework of patient safety 3
1.3 Organization of this book 6
2 Patient safety: definitions, theories, and measurement 7

2.1 Definitions of concepts relevant to patient safety 7
2.2 Conceptual framework of patient safety processes 8
2.3 Measurement of patient safety outcomes 11
3 Individual level influences on patient safety 17

3.1 Work behavior and performance 18
3.1.1 Dimensions of work performance 19
3.1.2 Theories of work performance 22
3.2 Cognitive ability 23
3.3 Knowledge, skills, experience, and competencies 25
3.4 Decision making 29
3.4.1 Heuristics and biases in decision making 30
3.4.2 Shared decision making 32
3.5 Work motivation 33
3.5.1 Need theories of motivation 34
3.5.2 Expectancy theory 35
3.5.3 Goal setting theory 36
3.5.4 Self-efficacy 37
3.5.5 Reinforcement theory 38
3.5.6 Control theory 39
3.5.7 Equity theory and organizational justice 40
3.5.8 Social identity theory 42
3.5.9 Relational theory of work motivation 43
3.6 Personality 45
3.7 Attitudes and emotions 47
3.7.1 Attitudes 47
3.7.2 Emotions 51
3.8 Occupational stress 54
3.8.1 Work stressors 56
3.8.2 Strain 58
3.8.3 Resources 59
3.8.4 The transactional stress model 60
viii Table of contents
3.8.5 The job demands-control model 61

3.8.6 Stress management strategies 62
3.9 Ethical decision making 63
3.10 Summary 63
4 Job level influences on patient safety 65

4.1 Job design 65
4.2 Training and workplace learning 67
4.2.1 Training needs analysis and establishment of training objectives 70
4.2.2 Training selection and design 71
4.2.3 Training delivery 74
4.2.4 Training evaluation and gap analysis 76
4.3 Team training 77
4.4 Summary 80
5 Interpersonal and team level influences on patient safety 81

5.1 Patient participation 81
5.1.1 Interventions to increase patient participation 86
5.2 Communication 87
5.2.1 Communication between patients and health care professionals 89
5.2.2 Communication among health care professionals 91
5.2.3 Communicating errors 93
5.3 Teamwork 94
5.3.1 Team composition and diversity 95
5.3.2 Evidence-based principles for effective team performance 98
5.4 Leadership 100
5.4.1 Trait theories of leadership 103
5.4.2 Behavioral theories of leadership 103
5.4.3 Contingency theories of leadership 105
5.4.4 Leader-member exchange theory 105
5.4.5 Participative leadership 106
5.4.6 Transactional and transformational leadership 107
5.4.7 Destructive, ethical, and authentic leadership 108
5.4.8 Leadership interventions in health care 109
5.5 Summary 110
6 Organizational level influences on patient safety 111

6.1 Organizational culture and climate 111
6.2 Patient safety culture and climate 113
6.2.1 Dimensions of safety culture and climate 114
6.2.2 Measures of safety culture and climate 115
6.2.3 Antecedents of safety culture and climate 117
Table of contents ix
6.2.4 Consequences of safety culture and climate 119

6.2.5 Interventions to increase safety culture and climate 121
6.3 Summary 122
References 123
Index 137
1 Introduction
1.1 Purpose of this book
Almost a quarter of a century ago, in 1991, an influential study showed that errors
and adverse events in hospitals were much more frequent and widespread than many
professionals working in the health care industry had previously believed [1]. The
Institute of Medicine in the United States of America reacted by publishing a detailed
scientific report on errors caused by individual and broader system factors in different
areas of health care including medical practices, nursing homes, and hospitals (“To
err is human: Building a safer health system”) [2]. This report, as well as research con-
ducted by other international health care organizations [3, 4], not only confirmed the
previous findings on the epidemiology of errors and adverse events in health care but
also suggested several strategies to prevent them in the future. Since the publication
of these seminal studies several years ago, patient safety has become an increasin-
gly important topic internationally, and it has attracted the attention and interest of
academics and practitioners from multiple disciplines, ranging from medicine and
health sciences to social work and gerontology, as well as psychology and business.
The trend toward a greater focus on preventing errors and maintaining high levels
of patient safety over the past decades is not surprising, given that the health care
industry in developed countries, and in some developing countries such as China,
India, and Brazil, is growing at an exponential rate. This growth is due to continuous
improvement in health care technology and procedures, increased individual aware-
ness and subjective importance surrounding health issues, and rapidly aging popu-
lations worldwide. At the same time, researchers estimate that ten per cent of patient
admissions to acute care in hospitals are due to the short- or long-term consequen-
ces of suffering caused by medical errors. Such impairments, where the underlying
causes are in the process of health and medical care, are called iatrogenic harm. Iat-
rogenic harm is now considered to be one of the top five public health problems in
developed countries [5]. According to estimates by the United States Institute of Medi-
cine, between 44,000 and 98,000 patients still die every year due to medical errors
[6]. Thus, while academics’ and practitioners’ interest and competencies related to
patient care are steadily increasing, these statistics suggest that further integrative
research on the various factors that help prevent errors and improve patient safety is
needed.
The present book examines the topic of patient safety from a psychological
perspective. Psychology is a theoretically grounded and empirical science as well
as a profession that is concerned with understanding, predicting, and potentially
changing human experience and behavior. In addition, psychologists are interes-
ted in the organization of human behavior in social groups, as well as the reciprocal
exchange relationships between humans and their material and social environment.
2 1 Introduction
A psychological perspective on patient safety is an important addition to other

disciplinary perspectives on the topic, as human experience and behavior can be both
causes and consequences of patient safety-related events. In addition, a psychologi-
cal approach to person-environment interactions is relevant to a better understan-
ding and potential improvement of patient safety because health care professionals
anticipate, make, and deal with the outcomes of errors in social and organizational
settings.
The psychological approach to the topic of patient safety taken in this book is
mainly informed by theoretical frameworks that were developed and tested within the
area of work and organizational psychology. Work and organizational psychology is
a subfield and area of specialization within psychology that attempts to understand,
predict, and possibly change people’s experiences and behaviors in work settings,
including medical practices and larger health care organizations [7]. Academics and
practitioners trained in work and organizational psychology apply scientific theories
and methods to improve processes and outcomes (e.g., well-being and performance)
in work and organizational settings. They use the insights gained from practice, in
turn, to inform and advance theorizing and research. This approach is called the
“scientist-practitioner model.” For instance, work and organizational psychologists
have conducted scientific studies to understand and predict the causes of errors and
accidents in hospitals by studying the concept of organizational safety climate (i.e.,
shared perceptions and attitudes among employees regarding patient safety) [8]. At
the same time, leadership and team training programs that were developed based on
this research on organizational safety climate may be implemented in hospitals to
improve patient safety.
While a psychological approach necessarily emphasizes the perspective of the
individual person and health care professional with regard to patient safety, this does
not imply that contextual and system factors that may be causes of medical errors and
threats to patient safety are neglected in this book. Individual, job, team, and orga-
nizational factors may influence these outcomes, both additively (i.e., independent
main effects) and multiplicatively (i.e., interactive effects). For instance, interactions
among health care professionals and between health care professionals and patients
may take place in work environments that are characterized by routines and a great
deal of predictability such as private medical practices. Yet these interactions may
also take place in very dynamic and challenging work environments such as emer-
gency rooms or acute psychiatric care [9]. Both individual factors, such as clinical abi-
lities, decision making, and attitudes toward safety, as well as interpersonal factors,
such as communication and teamwork, may contribute to errors and threats to patient
safety in these situations (main effects). Furthermore, due to their individual charac-
teristics, some health care professionals may work more or less successfully in one or
the other job or organizational setting (interaction effects). Patient safety in health
care organization is the result of a complex interplay between multiple factors that
exist at different “levels”: the individual, the job, the team, the organization, or even
the broader health care system. This book, therefore, examines patient safety from
a “multilevel perspective” that includes individual factors, job characteristics, inter-
personal and team influences, as well as organizational factors that contribute to, or
impede, patient safety.
1.2 A multilevel framework of patient safety
The multilevel framework of patient safety is illustrated in Fig. 1.1. Moving from the
center to the periphery, individual, job, interpersonal and team, organizational, and
societal and economic factors, as well as specific examples for these factors are depic-
ted at the nested layers of this “onion model.” The first central idea of this framework
is that the different factors may, as indicated by the arrows, influence each other in
a top-down and bottom-up manner. For instance, societal factors (e.g., government
regulations) may influence how health care organizations design and implement their
safety procedures, and team factors such as trust may influence whether individual
Societal context
Health care context Latent

Organizational factors
factors
Interpersonal and
team factors
Job factors
Individual Active
factors factors
Examples:
Knowledge
Stress
Examples:
Job design
Training
Examples:
Communication
Leadership
Examples:
Latent
Safety culture and factors
climate
Fig. 1.1: A multilevel framework of factors influencing patient safety

4 1 Introduction
employees report errors to their managers. Alternatively, individual employees may

also take the initiative and suggest new ways to approach the critical safety issues,
and organizations with a highly positive patient safety culture may serve as outstan-
ding examples for other organizations in the health care industry. The second central
idea is that specific factors may, both by themselves and in interaction with other
factors on the same or different levels, impact on patient safety. The individual factors
examined in this book in relation to patient safety include people’s work behaviors
and a number of individual differences that influence these behaviors: abilities (par-
ticularly cognitive abilities); knowledge, skills, and experience; decision making;
motivation; personality; attitudes and emotions; stress and well-being; and ethical
reasoning.
The job factors discussed in this book include job design and training. Psycho-
logical research on job design examines how the key characteristics of a job may
structure, motivate, or constrain people’s work behavior. This book will examine how
the design of health care jobs may influence safety-relevant work behaviors. Psycho-
logical training research investigates how effective training programs are planned,
selected, designed, carried out, and evaluated. This book will also focus on types of
training that may be particularly useful with regard to teaching patient safety know-
ledge and skills, as well as changing patient safety attitudes.
The interpersonal and team factors reviewed in this book include patient partici-
pation, communication, teamwork, and leadership. Patient participation is becoming
an increasingly important topic in health care, and research has shown that, under
certain circumstances, patients can be successful “co-creators” of their own care and
safety. Effective communication is a key contributor to patient safety, and this book
will discuss both effective communication among health care professionals and effec-
tive communication between health care professionals and patients. Teamwork and
leadership involve further interpersonal processes that may influence patient safety,
and both theoretical approaches to teamwork and leadership, as well as empirical
findings on these two topics will be reviewed.
Finally, the organizational factors in the multilevel framework that will be exami-
ned in this book are organizational safety culture and climate. These shared beliefs
about the importance of safety and shared perceptions of safety practices in the work-
place have been shown to have significant influences on employees’ safety-related
motivation and behavior as well as objective safety outcomes such as error rates and
accidents.
Fig. 1.1 also shows that factors of the broader health care and societal context (e.g.,
political, legal, historical, and cultural factors) are part of an integrated, multilevel,
and systems perspective on patient safety, but a detailed discussion of these distal
factors is beyond the scope of this book. Consistent with a psychological approach,
the multilevel framework used in this book has the health care professional and its
individual characteristics at its core. This conceptualization also follows the widely
accepted notion that health care professionals’ decision-making and behavior are the
most proximal causes of errors, adverse events, threats to patient safety, and injuries.
However, the framework also recognizes that the behavior of individuals can be
caused by factors both within and outside the person, including more proximal (e.g.,
job design) and more distal (e.g., organizational culture) external factors.
The multilevel framework is also consistent with an approach to errors and safety
in complex systems that has distinguished between active and latent failure [10].
Active failure refers to errors made by employees performing a task. In contrast, latent
failure involves system-based errors that are due to external factors, for instance,
careless equipment maintenance, incorrect management decisions, and excessive
workload. The approach assumes that latent failures can lead to active failures under
specific constellations of external circumstances or due to interactions between
higher-order external and individual factors.
The structure of the multilevel framework used in this book is further similar to a
recently developed, evidence-based framework of factors that contribute to errors and
patient safety in hospitals [11]. The “Yorkshire Contributory Factors Framework” was
developed based on a systematic review of the contemporary patient safety literature
from various data sources. The authors extracted over 1600 contributory factors from
95 articles reporting 83 studies, and coding by two independent raters resulted in
20 thematic domains. The majority of studies included in the review identified health
care professionals’ behavior as the most proximal contributing factor to patient safety
incidents (i.e., active failure, including mistakes, lapses, and violations). The second
most frequently studied contributing factors were other individual factors (e.g., experi-
ence, stress, personality, and attitudes), job factors (i.e., equipment and supplies, lines
of responsibility, physical work environment, scheduling and bed management, staff
workload, task characteristics, training and education), interpersonal and team factors
(i.e., communication, management of staff, supervision and leadership, and patient and
team factors), organizational factors (i.e., organizational policies and procedures, safety
culture, support from central functions such as information technology and human
resources), and broader context factors (i.e., external policy context). Thus, the “Contri-
butory Factors Framework” confirms the importance of approaching patient safety from
a psychological, multilevel, and systems perspective as it is done in this book.
Finally, the use of a multilevel framework is in line with research on health care
professionals’ views on the contributing factors of patient safety. In one study, resear-
chers asked operating room nurses what they believed were the most important influ-
ences on patient safety [12]. The nurses nominated individual psychological factors as
the most important contributors to patient safety, which included decision-making,
knowledge, and experience, as well as concentration difficulties, emotional exhaus-
tion, and fatigue. In addition, the nurses mentioned factors on other levels as relevant
factors, including work demands, control over work situations and scheduling, good
team coordination and mutual trust, and organizational safety culture. These factors
identified by the nurses based on their daily experiences clearly mirror the structure
of this book’s multilevel framework.
6 1 Introduction
1.3 Organization of this book
This book is structured according to the multilevel framework depicted in Fig. 1.1,
starting at its center and moving to its periphery. After an introduction to important
definitions and theories and methods used to measure patient safety (chapter 2), poten-
tial individual factors that contribute to patient safety will be reviewed (chapter 3).
The following two chapters will address job factors (chapter 4) and interpersonal and
team factors (chapter 5) as predictors of patient safety. Finally, chapter 6 will examine
patient safety-relevant factors that are located at the organizational level.
2 Patient safety: definitions, theories,
and measurement
2.1 Definitions of concepts relevant to patient safety
Researchers affiliated with the World Health Organization’s (WHO) “World Alliance
for Patient Safety” have argued that, for a long time, an important limitation of the
patient safety literature had been the use of inconsistent concept labels and defini-
tions. To address this problem, they proposed a set of preferred concept labels and
definitions [13]. The researchers used various sources (e.g., dictionaries, scientific
literature, and internet searches) to identify 48 key patient safety concepts based on
six agreed upon principles:
– The concepts can be applied in all areas of health care
– The concepts are consistent with other classifications used by the WHO
– The concepts and their definitions use colloquial language
– The definitions accurately reflect the meaning of patient safety concepts
– The definitions are short and clear
– The concepts will be part of an international patient safety classification system
The use of standardized, agreed upon key concept labels and definitions, in both
the scientific and applied patient safety literature, is important because it allows
for an improved mutual understanding and communication among patients,
health care practitioners, and researchers. It also avoids confusion and unne-
cessary work, and therefore facilitates the work of researchers and practitioners.
Table 2.1 presents the concepts and definitions from the resulting “international
patient safety classification” that are of the greatest relevance for this book [13].
Based on the suggestion of the “World Alliance for Patient Safety,” patient safety
is defined in this book as “the reduction of risk of unnecessary harm associated
with health care to an acceptable minimum” [13]. This definition includes con-
cepts, that are also explained in Tab. 2.1, based on the proposed patient safety
concept definitions [13]. Specifically, “risk” is defined as the probability that an
incident (i.e., an event or circumstance that could have resulted, or did result, in
unnecessary harm to a patient) will occur. “Harm” is defined as the impairment of
structure of function of the body and/or any deleterious effect arising from this.
Harm may include impairments such as disease, injury, suffering, disability, and
death. Finally, “ health care” refers to services received by people or communities
as a whole to promote, maintain, monitor, or restore health (i.e., as defined by the
WHO, a state of complete physical, mental and social well-being and not merely
the absence of disease).
8 2 Patient safety: definitions, theories, and measurement
Tab. 2.1: Key concepts and definitions of patient safety concepts; adapted from [13]
Concept Definition
Patient A person who is a recipient of health care.

Health care Services received by individuals or communities to promote, maintain,
monitor, or restore health.
Health A state of complete physical, mental and social well-being and not merely the
absence of disease or infirmity (WHO definition).
Safety The reduction of risk of unnecessary harm to an acceptable minimum.
Harm Impairment of structure of function of the body and/or any deleterious effect
arising there from. Harm includes disease, injury, suffering, disability, and
death.
Patient safety The reduction of risk of unnecessary harm associated with health care to an
acceptable minimum.
Patient safety An event or circumstance that could have resulted, or did result, in
incident unnecessary harm to a patient.
Hazard A circumstance, agent, or action with the potential to cause harm.
Error Failure to carry out a planned action as intended or application of an incorrect
plan.
Violation Deliberate deviation from an operating procedure, standard, or rule.
Risk The probability that an incident will occur.
Near miss An incident that did not reach the patient.
No harm incident An incident that reached the patient but no discernable harm resulted.
Harmful incident An incident that resulted in harm to a patient.
(also called
adverse event)
Injury Damage to tissues caused by an agent (i.e., a substance, object or system that
acts to produce change) or event.
2.2 Conceptual framework of patient safety

processes
In addition to providing a comprehensive set of patient safety concepts and defi-

nitions, the WHO’s “World Alliance for Patient Safety” assembled an international
network of experts from, among others, the fields of patient safety, classification
theory, health informatics, consumer and patient advocacy, law, and medicine, to
draft a conceptual framework that outlines relationships between different concepts
involved in patient safety [14].
The scientific goal of this framework is to provide a theoretical model to investi-
gate the factors and processes involved in patient safety as they unfold over time. The
practical goals associated with this framework are to gain a better understanding of
the processes involved in patient safety, to derive strategies to reduce risks for, and
harm of, patients, to provide a basis for evidence-based research, and to evaluate
2.2 Conceptual framework of patient safety processes 9
health care providers’ existing policies, practices, and procedures. The framework
consists of ten higher-order factors [14]:
– Contributing factors and hazards
– Incident type
– Patient characteristics
– Incident characteristics
– Detection
– Mitigating factors
– Patient outcomes
– Organizational outcomes
– Ameliorating actions
– Actions taken to reduce risk
The conceptual framework and definitions of the ten higher-order factors provided by
the “World Alliance for Patient Safety” are shown in Fig. 2.1. According to the frame-
work, contributing factors and hazards can lead to different types of patient safety
incidents, which can be further described by various patient and incident charac-
teristics. A patient safety incident may or may not be detected once it occurred. This
detection process involves different stakeholders such as patients, health care profes-
sionals, emergency service employees, other patients, friends and family members of
the patient. In addition, the detection of patient safety incidents involves individual
and environmental processes such as error recognition, change in patient’s status,
alarms and other automated or environmental changes, standardized and routine
audits or reviews, and proactive risk assessments [14].
As shown in next step in the framework in Fig. 2.1, mitigating factors may prevent
negative effects of patient safety incidents on the patient and organizational outco-
mes. These mitigating factors may include patient-directed behaviors carried out by
health care professionals (e.g., treatments, referrals, education, explanations, or apo-
logies), employee-directed actions (e.g., effective supervision, team work, and com-
munication), organization-directed actions (e.g., use of effective protocols, correction
of documentation errors, and availability of equipment), or safety equipment-direc-
ted actions (e.g., use of security measures and infection control strategies, correction
of equipment usage error) [14].
Incident detection and mitigating factors may weaken, slow down, or even dis-
continue the harmful effects of patient safety incidents on patient outcomes. However,
once patients and the organization have been affected by a harmful incident, ameli-
orating actions may be taken in the next step to compensate for the harm caused by
the incident. Two specific examples of ameliorating actions on behalf of health care
professionals or the organization are apologizing to the patient or changing the safety
culture of the organization. The final step in the framework, actions taken to reduce
the risk of patient safety incidents from re-occurring in the future, influence and are
Contributing
factors/hazards
Circumstances, actions, or
influences which lead to an
incident or increase the risk
of an incident.
Patient characteristics Incident type Incident characteristics

Includes factors such as Category of an event or Includes information such as
patient demographics, circumstance that resulted, or where and when the incident
original reasons for seeking could have resulted, in occurred, who was involved,
care, and the primary unnecessary harm to a and who reported it.
diagnosis. patient.
Detection
Action or circumstance that
leads to the discovery of an
incident.
Mitigating factors
Actions or circumstances that
prevent or weaken the
harmful effects of an incident
on the patient.
Patient outcomes Organizational outcomes

Impact on a patient, which is Impact on an organization,
wholly or partially due to an which is wholly or partially
incident (includes type of due to an incident (includes
harm, degree of harm, and increased use of resources
social/economic impact). and legal consequences).
Ameliorating actions
Actions taken or
circumstances altered to
improve or compensate for
harm due to an incident.
Actions taken to
reduce future risk
Steps taken to prevent the
re-occurrence of patient safety
incidents and improving
system resilience.
Fig. 2.1: A conceptual framework of patient safety processes; adapted from [14]
influenced by contributing factors and hazards, detection, mitigating factors, patients

and organizational outcomes, and ameliorating actions. The goal of these proactive stra-
tegies is to reduce, better manage, or control harm due to patient safety incidents in the
future. Examples for such strategies include patient-directed actions such as providing
adequate care, employee-directed actions such as training, and organization-directed
actions such as leadership training and establishing an organizational safety culture.
This book is mainly concerned with the different contributing factors and hazards
that lead to patient safety incidents as well as the mitigating factors and actions taken
to reduce risk; these factors and actions may be located on the individual, job, inter-
personal and team, or organizational levels. Examples for such factors provided by
the authors of the conceptual framework include human factors such as work beha-
vior and communication; system factors such as the work environment; and contex-
tual factors such as legislative policy [14]. The authors also note that usually more
than one contributing factor or hazard is involved in a patient safety incident, which
is consistent with the multilevel approach taken in this book.
The conceptual framework provided by the “World Alliance for Patient Safety”
represents an important step toward a more systematic description and understan-
ding of patient safety processes from both a scientific and a practical perspective.
In addition to this useful framework, other theories from different scientific discipli-
nes may inform investigations and applications related to patient safety. Researchers
have summarized a number of theories that have been used to examine organizatio-
nal changes, quality improvement, and other ways to increase patient safety in health
care [15]. An overview and description of three broad types of such theories—process
theories, stages of change theories, and impact theories—is provided in Tab. 2.2.
Table 2.3 provides a more detailed overview and description of different impact
theories. Theories with a focus on individuals explain how health care professionals
make decisions, become motivated, and initiate actions. Theories on social interac-
tions among health care professionals describe the factors that influence interindi-
vidual processes, including the role of leaders and team members. Theories related
to the organizational context focus on the organizational conditions that may help
improve patient care, including the design of jobs and organizational culture and
climate. Finally, theories on the political and economic context of patient care focus
on the broader context surrounding health care organizations, which includes politi-
cal regulation, legal requirements, and economic market conditions.
2.3 Measurement of patient safety outcomes
Health care researchers and practitioners have developed different methods to

measure and evaluate patient safety outcomes, such as the occurrence of medical
errors and harmful incidents. A review article discussed the advantages and
disadvantages of eight commonly used methods to assess errors and harmful
Tab. 2.2: General typology of theories of change in health care; adapted from [15]
Type of theories Description
Process Process theories focus on courses of action and developments over time and
theories the implementation of changes that benefit patient safety (e.g., planning,
organization, and utilization).
Stages of Stages of change theories focus on specific steps that individual employees
change or teams must take to achieve intended changes in patient safety. Stages may
theories include:
– Orientation: includes becoming aware of needs, possibilities, and
innovations
– Insight: includes gaining an understanding and insight into routines
– Acceptance: includes the forming of positive attitudes and making the
decision to change
– Change: includes the actual adoption and confirmation of value
of intervention
– Maintenance: includes integration of new practices into routines and
embedding new practices in the organization
Impact theories Impact theories focus on the assumptions regarding how a specific intervention
will facilitate intended changes in patient safety (including causes, effects, and
boundary conditions).
Tab. 2.3: Overview and description of theories of change in health care; adapted from [15]
Focus Type of theories Description
Individuals Cognitive theories Cognitive theories focus on the decision making

(health care processes of health care professionals, and the
professionals) internal and external factors that facilitate or hinder
effective decision making.
Educational theories Educational theories focus on the intrinsic
and extrinsic motivation to learn, health care
professionals’ learning styles, and experience-based
learning and change.
Motivational theories Motivational theories focus on health care
professionals’ motivation, attitudes, perceptions,
and intentions.
Interpersonal and Communication Communication theories focus on the drivers of
social context theories effective communication, including characteristics of
the message, the message sender, and the message
recipient.
Social learning Social learning theories focus on vicarious learning
theories through the modeling of others people’s behavior,
and on social reinforcement of desired outcomes.
(Continued)
Table 2.3: Overview and description of theories of change in health care; adapted from [15]
(continued)
Focus Type of theories Description
Social network and Social network and influence theories focus on

influence theories the structure of social networks and the role of
specific employees in these networks, and how they
influence the dissemination and adoption of new
ideas, processes, and technologies.
Teamwork theories Teamwork theories focus on the characteristics of
effective teams, such as goal clarity and knowledge
sharing.
Professional Professional development theories focus on
development theories professional standards and the influence of
professional bodies on health care professionals’
development.
Leadership theories Leadership theories focus on the characteristics and
behaviors of leaders that influence change.
Organizational Innovation theories Innovation theories focus on team and organizational
context characteristics that facilitate or prevent the
successful implementation of innovations in health
care.
Quality management Quality management theories focus on the
theories continuous improvement of health care processes
and continuous adaptation based on experience to
benefit customers.
Integrated care Integrated care theories focus on the
theories multidisciplinary and collaborative nature of health
care processes.
Complexity theories Complexity theories focus on the observation
and improvement of whole systems and
overall patterns of individual and organizational
behavior.
Organizational learning Organizational learning theories focus on the
theories creation, acquisition, and transfer of knowledge as
well as on the conditions for continuous learning and
adaptation.
Organizational culture Organizational culture theories focus on how positive
theories organizational cultures can promote safety and
organizational effectiveness.
Political and Reimbursement Reimbursement theories focus on individual and
economic context theories organizational decisions as well as rewards and
incentives to optimize goal achievement.
Contracting theory Contracting theories focus on the formal
arrangements that influence health care services by
assessing the needs of populations and establishing
care priorities.
incidents in health care. The review can be used by health care researchers and
practitioners to choose a method to detect latent failures (i.e., system errors), active
failures (i.e., employee behavior), and harmful incidents (i.e., adverse events resulting
from errors) [16]. Table 2.4 provides an overview of these methods.
Health care researchers have also developed numerous measures of factors con-
tributing to patient safety. Depending on the type of measure (e.g., a survey, a test,
or a behavioral observation), different stakeholders are involved in the assessment
process. Very common in the literature are survey measures of medical students’ and
health care professionals’ attitudes toward patient safety-related issues. For instance,
researchers aimed to develop a relatively simple, practical, reliable, and valid method
to measure patient safety attitudes among medical students [17]. They created the
“Attitudes to Patient Safety Questionnaire,” which consists of 45 survey questions on
students’ attitudes regarding five patient safety themes (i.e., general perceptions of
errors, error causation, error improvement strategies, error reporting, and learning
and teaching issues).
Tab. 2.4: Methods to measure errors and harmful incidents; partly adapted from [16]
Method Description
Morbidity and mortality Frequent conferences held in hospitals and medical practices that
conferences involve peer reviews of errors that occurred during patient care. The
goals are to learn from errors and to change decisions and behaviors
based on experience.
Autopsy Post-mortem procedure that involves a thorough examination of a body
to establish the cause and manner of death.
Malpractice claims file An analysis of medical records and other official files that may help to
analysis identify the leading causes of medical errors and identify opportunities
for prevention of errors.
Error reporting systems Reporting of errors witnessed or committed by health care providers
using structured data collection systems such as surveys and
interviews.
Administrative data Analysis and coding of administrative or billing data, including hospital
analysis discharge data.
Chart review Retrospective examination of medical records data that have been
recorded for reasons other than research.
Electronic medical Computer-based search of electronic medical records that allows
record review monitoring in real time and integrating multiple data sources.
Observation of patient Observing or videotaping of actual patient care behaviors in operating
care rooms, intensive care units, and surgical wards.
Clinical surveillance Observation, data coding, and analysis of health data of a clinical
syndrome over time.
Self-report and other- Use of questionnaires to gather health care professionals’ as well as
report surveys their coworkers’ and supervisors’ perceptions of medical errors and
risks to patient safety.
Other researchers have developed and validated complex tests to measure

health care trainees’ and professionals’ levels of patient safety knowledge. For
instance, a group of researchers used a test with 14 safety-related questions to assess
640 medical students’ patient safety knowledge [18]. In addition, the researchers
assessed students’ background characteristics and their subjective perceptions of
their patient safety knowledge. The results showed that, on average, students answe-
red 58% of questions correctly. In addition, level of patient safety knowledge varied
significantly with students’ year of training, degree, and specialty. Interestingly,
the results further showed that students were not able to assess reliably their own
patient safety knowledge.
Another group of researchers developed a measure of the factors that contri-
bute to patient safety from the patients’ perspective [19]. Their “Patient Measure of
Safety” is based on 20 contributory factors from the “Yorkshire Contributory Factors
Framework” [11] and one additional factor not included in the framework, dignity and
respect. The researchers found that the patients in their study identified individual
and interpersonal factors (e.g., communication) more frequently as contributors to
patient safety than organizational factors.
3 Individual level influences on patient safety
This chapter will describe individual or person factors that may impact on patient
safety processes and outcomes. Psychological definitions and explanations of work
behavior and work performance will be provided first, as it is generally assumed that
health care professionals’ behavior is often the most proximal cause of errors and
harmful incidents. The subsequent sections describe several individual factors and
processes that have been shown to influence health care professionals’ work behavior
and performance, including their cognitive abilities; knowledge, skills, and experi-
ence; decision making; motivation; personality; attitudes and emotions; stress and
well-being; and ethical reasoning.
In the field of psychology, the term “individual differences” is generally used to
describe individual factors for which relatively enduring or stable differences exist
between persons. In other words, these characteristics vary more or less in a given
group of people. Work and organizational psychologists have used information on
individual differences for a long time to predict employees’ behavior in the work-
place. Their research has shown that individual differences in characteristics such as
ability, personality, and motivation are related to a wide variety of work behaviors and
important work outcomes. The area within psychology that involves the development
of surveys, tests, and other assessment techniques to measure individual differences
in order to predict later work behavior is called “psychometrics.”
While a broad range of individual differences will be discussed in relation to
patient safety in this chapter, it is important to note that some of these individual
differences may be more useful than others in terms of understanding and predic-
ting behaviors relevant for patient safety. In addition, no single individual difference
characteristic can explain 100% of the variation in safety-related behavior in a group
of health care professionals. However, researchers and practitioners may use several
tests or surveys to assess a number of important individual differences in order to
maximize their predictive validity.
Three further caveats need to be pointed out with regard to individual differences
and patient safety. First, the importance or predictive validity of individual differences
for safety-relevant work behaviors may also depend on characteristics of the health
care professional’s job, as well as the organizational context. Some work environ-
ments may require higher levels of an individual difference in order to maximize
patient safety, whereas other work environments are better able to substitute or
“buffer” low levels of safety-relevant individual differences. For example, complex
and dynamic work environments such as operating rooms may require higher levels
of information processing capacity than private medical practices. On the other hand,
warning signs and alarms in hospitals may protect health care employees with rela-
tively low levels of cognitive ability (e.g., memory problems) from causing harmful
incidents. Second, in contrast to many individual differences, work behavior and
18 3 Individual level influences on patient safety
performance are usually not stable over time and may fluctuate across hours, days,
and months. Thus, it is important to keep in mind that individual differences may be
used to predict employees’ average or typical levels of work behavior, to predict their
variability in behavior, or both.
Finally, it is important to keep in mind that research on the associations between
health care professionals’ individual differences and work performance on the one
hand and patient safety incidents on the other may be controversial, as individuals
have a general tendency to take credit for positive outcomes and to blame negative
outcomes on other people or external factors (i.e., self-affirmation bias [20]). This ten-
dency is demonstrated by research on the determinants of patient safety incidents.
For instance, a study with 88 nurses examined nurses’ explanations of the reasons
of diagnostic errors during assessments of patients with chest pain [21]. The most
frequently mentioned reasons for errors reported by the nurses were patients’ condi-
tion, work overload, lack of time, incorrect documentation, and the involvement of
different nurses in the assessment. Thus, nurses nurses explained the vast majority
of errors with external or environmental factors rather than with their own characte-
ristics, such as lack of knowledge, competence, or emotional exhaustion.
3.1 Work behavior and performance
Psychologists are interested in understanding, predicting, and possibly changing

people’s behavior. It is assumed in this book that an understanding of health care
professionals’ behavior at work is important to maximize patient safety and minimize
errors and harmful incidents in health care settings. Over the past two decades, work
and organizational psychologists have conducted numerous studies to gain a better
understanding of, and to predict different forms of, employees’ work behavior, that
is, their work performance. Work performance is defined as employee behavior that
contributes to the goals of the organization and can be measured in terms of each
employees’ proficiency [22]. These researchers have characterized work performance
as something that employees actually do, including their observable work-related
actions (e.g., performing an operation) but also work-related thinking, planning, and
problem solving (e.g., staffing in a hospital). Health care professionals’ work perfor-
mance therefore includes those behaviors and actions that can be evaluated with
regard to the extent to which they help fulfill the goals of their organization. These
organizational goals are not limited to, but may include ensuring patient safety and
patient satisfaction, helping cure patients and avoiding harm, minimizing costs and
maximizing profits, and complying with safety standards and legal requirements.
An important distinction exists between employees’ work performance and
the concept of productivity and effectiveness [22]. Work performance is defined as
behavior and not as the consequence or result of behavior. In contrast, productivity
and effectiveness refer to the measurable outcomes of employees’ work behavior.
For instance, the number of patients treated per day in a medical practice, the
number of harmful incidents per month in a hospital, or the profit of a private
medical clinic do not constitute work behavior or performance per se but may be,
at least in part, outcomes of employees’ work performance. The reason for this dis-
tinction between work performance and productivity is that employees often have
only limited control over the individual, unit-level, or organizational outcomes of
their behavior. These objective outcomes are also caused or constrained by other
factors in the organizational environment, such as other people working toward
the same goal (e.g., colleagues and supervisors), availability of resources, as well as
external and uncontrollable factors. Thus, variations in productivity, effectiveness,
or patient safety outcomes are often due to external factors that are not under the
individual employee’s influence.
3.1.1 Dimensions of work performance
Work performance is not a homogeneous construct but consists of multiple distinct

but related behavioral dimensions. For instance, a nurse may contribute to the orga-
nizational goal of patient safety by complying with hospital standards and rules, but
may also engage in more discretionary behaviors that are not formally required by
the organization but may nevertheless benefit patient safety, such as volunteering to
help colleagues and supervisors in crises, or proactively identifying potential safety
threats. Accordingly, work and organizational psychologists have “sliced” the crite-
rion domain of work performance into several different components. In the following,
the focus will be on six well-established forms of work performance that are related to
maintaining and improving patient safety:
– Task performance
– Citizenship (or contextual) performance
– Counterproductive performance
– Adaptive performance
– Proactive performance
– Safety-related performance
Task performance refers to an employee’s proficiency in carrying out the core tasks,
responsibilities, and assignments of his or her job [23, 24]. These core job elements are
formally required and rewarded by the organization, and are usually explicitly menti-
oned in the job contract or job description. For instance, a core task of surgeons is to
remove body parts that have been infected or injured. A core task of nursing assistants
working in the operating room is to prepare the patient for an operation. Task perfor-
mance is an important contributor to patient safety to the extent that ensuring and
maintaining patient safety is a formal requirement and explicit goal of the employee’s
organization.
Citizenship (or contextual) performance involves discretionary and not required

employee behaviors that contribute to task fulfillment and the effective functioning
of teams and the organization as a whole [23]. Researchers have further divided the
citizenship performance construct by distinguishing between interpersonal helping
or altruistic behaviors (e.g., helping a new colleague with a problem) and compliance-
related behaviors such as coming to work on time, not wasting company time,
upholding company rules, and defending the organization when talking to out-
siders [25]. It is easy to imagine how both types of citizenship performance may
contribute to patient safety in health care settings in addition to high levels of task
performance. Voluntary helping and supporting behaviors should ensure patient
safety in stressful work situation when individual employees’ resources are taxed.
Alternatively, employee compliance should ensure patient safety to the extent that
effective policies, practices, and procedures regarding patient safety exist in the
organization.
Counterproductive performance is negatively related to task performance and
organizational citizenship behaviors. It involves “bad” discretionary employee beha-
viors that threaten the effectiveness and well-being of the organization (i.e., organi-
zational deviance) and of its employees (i.e., interpersonal deviance) by violating
other employees’ and the organization’s interests and norms regarding interpersonal
respect, customer service, and effective performance [26, 27]. Discretionary employee
behaviors such as stealing and damaging company property, sabotaging organizati-
onal processes, delivering low-quality outcomes, being late or being absent without
an excuse, taking excessively long breaks, surfing the internet for private purposes,
and abusing substances constitute organizational deviance. Discretionary employee
behaviors such as bullying, harassment, gossiping, verbal abuse, as well as acting
aggressively toward co-workers and patients constitute interpersonally deviant beha-
viors. Again, it is not difficult to imagine how counterproductive performance may
impact on patient safety in health care settings. Nurses, physicians, and other health
care professionals who behave inappropriately and ineffectively at their workplace,
who disrespect other employees and patients, or who sabotage organizational goals,
rules, and processes implicitly also risk harm to patients.
Adaptive performance involves employees showing high levels of openness, fle-
xibility, as well as the ability and willingness to adapt to challenging and changing
circumstances at work [28]. For instance, nurses and physicians who learn from pre-
vious medical errors and subsequently avoid them show high levels of adaptive per-
formance. Researchers have outlined eight dimensions of adaptive performance [28]:
– Handling emergencies and crisis situations
– Handling work stress
– Solving problems creatively
– Dealing with uncertain and unpredictable work situations
– Learning work tasks, technologies, and procedures
– Demonstrating interpersonal adaptability
– Demonstrating cultural adaptability

– Demonstrating physically-oriented adaptability
Most, if not all, of these dimensions may be important determinants of patient safety
outcomes. For instance, health care professionals who effectively handle emergen-
cies, crises and stress at work should be also more like to prevent or effectively deal
with challenging work situations that may cause patient harm. In addition, emplo-
yees who can deal effectively with uncertain as well as interpersonally, culturally, or
physically challenging work situations will be in a better position to avoid or manage
threats to patient safety. Finally, employees who quickly learn their work tasks, adapt
successfully to new technologies and procedures, and learn from past experiences
will be better prepared to ensure patient safety.
Proactive performance involves positive work behaviors that indicate high
levels of personal initiative and future-oriented work engagement that go above and
beyond expectations of the organization [29, 30]. Proactive employees notice threats
to patient safety and opportunities to increase patient safety in the unit or organiza-
tion before other employees, and work with dedication and persistence to make their
ideas reality. For instance, a health care professional who, driven by their own initia-
tive, investigates numerous possible ways to prevent future errors shows high levels
of proactive performance. Another example may be a human resource planner in a
hospital who proactively ensures that enough employees are available during a shift
in order to prevent threats to patient safety due to staffing shortages.
Finally, work and organizational psychologists have also explicitly conceptualized
and empirically investigated safety-related workplace behaviors [31]. Consistent with
the approach taken here to link different dimensions of work performance with patient
safety, these researchers have adapted the distinction between task performance and
more discretionary types of work behavior such as citizenship performance and proac-
tive performance to derive two components of workplace safety behavior [31]:
1. Safety participation: this type of safety performance involves employee activities
that do not directly contribute to an individual employee’s personal safety at work
but that help establish and maintain a work environment that values and sup-
ports safety. Specific employee behaviors that can be categorized as safety partici-
pation are involvement in voluntary safety activities (e.g., additional training and
mentoring), helping coworkers with safety-related issues, and attending safety
meetings. This form of safety performance is related to the broader categories of
citizenship performance, adaptive performance, and proactive performance.
2. Safety compliance: this type of safety performance consists of the core tasks and
activities that employees are required to carry out by their employer in order to
maintain safety in the workplace. Specific employee behaviors belonging to this
performance dimension include complying with standard work policies, practices,
and procedures. This form of safety performance is related to the broader categories
of task performance, but also to an aspect of citizenship performance (compliance).
3.1.2 Theories of work performance
In their theorizing, work and organizational psychologists have proposed that

work performance (including the different dimensions of work performance dis-
cussed in the previous section) is determined by three, and only three, proximal
factors [22, 32 ]:
1. Declarative knowledge: knowledge about concepts and facts (for example, a
health care professional possesses factual knowledge about a medical procedure:
who invented it, how often it is employed, and how safe it is considered by others
in the field).
2. Procedural
knowledge and skills: knowing how to do things (for example, a health
care professional has an understanding of how to perform an operation in a safe
way).
3. Motivation: the discretionary choices that employees make (for example, a health
care professional chooses to go to work and to perform a task that is safety rele-
vant, she chooses the level of effort she is willing to invest to ensure patient safety,
and chooses how long she will persist investing effort into task fulfillment).
Individual differences, such as cognitive abilities and personality characteristics, as

well as contextual factors, such as job, team, and organizational characteristics are
indirectly related to work performance [22]. Specifically, these more distal person
and environmental factors can only influence work performance by changing emplo-
yees’ levels of declarative knowledge, procedural knowledge and skills, and motiva-
tion. According to this theory, health care professionals’ personal characteristics and
factors of their work environment will, by themselves and in interaction, influence
their knowledge, skills, and motivation that, in turn, influence their level of work
performance. These processes are depicted in Fig. 3.1 (dotted arrows indicate inter-
active effects of individual and contextual factors on the proximal determinants of
Individual
difference
factors
Declarative knowledge,
procedural knowledge
and skills, motivation
Job, team, and

organizational Safety
factors performance
Fig. 3.1: Influences on work behavior and performance

3.2 Cognitive ability 23
work performance). It is important to keep in mind that health care professionals’

work performance is, if at all, only one of the determinants of patient safety outco-
mes. Contextual factors at the job, team, and organizational levels may also affect
patient safety as well as constrain or boost the effect of work performance on patient
safety.
In addition to conceptualizing different “content dimensions” of work perfor-
mance (such as task and citizenship performance), work performance researchers
have made another important distinction with relevance for the topic of patient
safety. Specifically, they have distinguished between typical and maximum levels of
work performance [33]:
1. Maximum work performance: this concept refers to employee work behavior that
requires the employee’s highest possible level of effort (i.e., 100%). In other words,
maximum performance involves the highest level of performance an employee
can demonstrate given his or her ability, knowledge, and skills (and assuming
the highest possible level of motivation). For instance, during a complex and non-
routine operating procedure, a surgeon needs to show maximum performance to
ensure the highest level of patient safety.
2. Typical work performance: this concept refers to employee work behavior that
requires less effort than maximum performance (e.g., 50%). In other words, to
achieve a typical level of performance, an employee does not have to activate his
or her full ability as well as knowledge, skills, and motivation. For instance, a
nurse may invest a typical level of work performance while following standard,
routine work procedures (e.g., hand hygiene) that are nevertheless crucial to
ensure patient safety.
Only a few jobs, especially highly complex jobs in which tasks are performed under
time pressure, involve many phases that require maximum performance. In most jobs
in the health care industry, work is usually not performed at maximum effort levels
but rather at typical levels. Research has shown that variation in employees’ level of
maximum work performance is best predicted by employees’ abilities, in particular
cognitive ability, as well as declarative knowledge. Variation in levels of typical work
performance are also predicted to some extent by employees’ abilities, but especially
by employees’ level of motivation and personality characteristics [34].
3.2 Cognitive ability
The term “abilities” refers to individual capacities or the “enabling” and “can do”
factors that allow people to show certain work behaviors, including work behaviors
that ensure patient safety. Two broad and important categories of human abilities are
cognitive abilities and physical abilities. In this book, the focus will only be on cogni-
tive abilities as predictors of work performance, as they have been the primary focus of
research in work and organizational psychology as well as in patient safety research.

In contrast, hardly any research has examined relationships between employees’
physical abilities (e.g., muscular strength, cardiovascular endurance, and movement
quality), sensory abilities (e.g., vision, hearing, smell, and touch), and psychomotor
abilities (e.g., coordination, dexterity, and reaction time) on the one hand and patient
safety behaviors and outcomes on the other.
Cognitive abilities involve different mental processes related to attention, percep-
tion, memory, reasoning, judgment, and problem solving. Researchers in psychology
have proposed and empirically shown that these various specific cognitive abilities,
while each may be important in their own right, have a common underlying basis
or factor. This higher-order factor, which represents a non-specific cognitive ability
and is also often called intelligence, general mental ability, or simply “g” is one of
the most frequently assessed individual differences in the field of psychology [35].
It describes a person’s general ability to learn, plan, reason, and solve problems in a
wide variety of different situations.
Cognitive ability is widely considered to be one of the most important individual
differences in psychology. This is particularly true for the field of work and orga-
nizational psychology, as cognitive ability is the best individual difference predic-
tor of both employee training and work performance, especially in highly complex
jobs that require high levels of information processing, such as surgery [36, 37].
However, research shows that cognitive ability is important in every job, including
less complex jobs, because every job requires some level of information processing.
Yet the more information processing is required in a given job, the more important
cognitive ability becomes with regard to predicting employees’ level of work perfor-
mance. Importantly, meta-analyses have shown that cognitive ability tests predict
approximately 50% of the variance in future work performance across a broad range
of jobs and, in terms of incremental predictive validity, other individual differences
add only very few percentages in terms of explaining additional variance in work
performance [38].
The reason that cognitive ability is the best predictor of work and training perfor-
mance is that employees with high levels of cognitive ability learn job-related know-
ledge and skills and training content more quickly, and are better in applying it on
the job than employees with low levels of cognitive ability [32]. It is important to note
that depending on the nature of the job and of the job’s responsibilities, other indivi-
dual differences such as personality and emotion regulation skills may also predict
employees’ work performance. For instance, in customer service jobs and when
working intensively with patients, emotional stability and the awareness of other
people’s emotions have been shown to play a crucial role.
Most health care professionals are required to process large amounts of infor-
mation (e.g., patients’ names, current and past health problems, co-morbidities, and
other patient characteristics) and to carry out cognitively demanding tasks in complex
and challenging work environments such as operating rooms on a daily basis. Thus, as
suggested by the psychological literature, cognitive ability is likely to be an important

predictor of work performance in these jobs. Employees with low levels of cognitive
ability may find themselves in a situation in which their job demands are greater than
their innate information processing resources. This imbalance in an employees’ “job
demand-abilities fit,” in turn, could lead to the occurrence of errors and harmful inci-
dents unless other factors that may substitute or compensate for low levels of cogni-
tive ability are available.
A literature review on abilities required of surgeons in the operating room
suggested that many adverse events are caused by a lack or failures in health care
professional’s cognitive abilities and not by a lack of technical knowledge and skills
[39]. The review identified a number of critical cognitive abilities that are all part of
general cognitive ability:
– Situation awareness
– Mental readiness
– Assessing risks
– Anticipating problems
– Decision making
– Adaptive strategies and flexibility
– Workload distribution
3.3 Knowledge, skills, experience, and competencies
As suggested by theoretical models of work performance, employees’ safety-related

knowledge and skills, as well as their personal and professional experiences on
which their knowledge and skills are based, are important predictors of their safety-
related work behaviors and performance that, in turn, may impact on patient safety
outcomes. Knowledge is defined as a more or less systematic mental collection
of specific and interrelated pieces of data and information about a topic or topic
area. Employees acquire job-related knowledge through formal education or trai-
ning programs as well as through more informal work and life experiences [40].
Research suggests that health care professionals’ knowledge is an important con-
tributor to patient safety. For instance, a study of patients who stayed in clinically
inappropriate hospital wards found that patients’ perceptions of nurses’ knowledge
predicted indicators of patient safety [41]. Another study aimed to identify the
causes of surgical errors by using malpractice claim file analysis. The results of the
study showed that a lack of technical knowledge and inexperience with procedures
were leading factors contributing to errors (41%), most closely followed by commu-
nication breakdowns in surgical teams (24%) [42]. Not surprisingly, the lack of tech-
nical knowledge contributed more to technical errors than to non-technical errors.
A third study on general safety performance found that both the breadth and depth
of safety knowledge positively predicted important safety performance factors,

including the use of protective equipment, engagement in work practices to reduce
safety risks, the communication of safety-related information, and the exercise of
employee rights and responsibilities with regard to workplace safety [43]. Consis-
tent with these single studies, a meta-analysis of antecedents of safety-related beha-
viors and outcomes found that safety knowledge is closely and positively related to
safety behaviors and, together with safety motivation, can be considered one of the
best predictors of safety behaviors [44].
Importantly, health care professionals’ patient safety knowledge should be
assessed using reliable and validated knowledge tests instead of self-report survey
measures of knowledge. A study with health care trainees found that trainees’ know-
ledge about patient safety was rather insufficient, and that trainees were not aware
of their own lack of knowledge and need for training (i.e., the relationship between
actual and self-assessed knowledge was low) [18].
Fortunately, intervention studies have shown that knowledge about patient
safety can be increased within relatively short time periods. An intervention study
that aimed to change medical students’ knowledge about patient safety and medical
fallibility reported that students’ knowledge improved significantly over the course of
a course on these topics [45].
Skills are based on employees’ procedural knowledge or knowledge about how to
do things. Different types of skills required for effective work performance exist. For
example, performing a complicated operation successfully requires technical skills,
whereas satisfactorily resolving a heated conflict with a patient requires interperso-
nal skills. Employees’ skills develop through continuous practice over different time
frames ranging from hours and days to weeks, months, and years [46, 47]. The deve-
lopment of skills is facilitated by employees’ cognitive ability (i.e., the ability to learn,
reason, and problem solve), existing knowledge, and other individual difference cha-
racteristics related to learning motivation (e.g., interest). Importantly, while the deve-
lopment of skills is in part determined by these individual differences and process
factors, skills can only be developed through continuous practice. Researchers have
coined the concept of safety skills, that is, specific skills of health care professionals
that are needed to work safely, anticipate errors, prevent errors and harm, and miti-
gate harm [48]. In addition, these researchers have proposed a set of non-technical
safety skills that includes cognitive skills, such as decision making, planning, and
situation awareness, as well as interpersonal skills, such as communication, team-
work, and leadership skills.
Health care professionals’ acquisition of knowledge and skills related to patient
safety is dependent on their experiences both in and outside of their workplace. Work
and organizational psychologists have developed several models to explain the nature
of and factors contributing to work experience. The most well-known of these work
experience frameworks consists of two broad dimensions, measurement mode and
level of specificity [49]. The measurement of work experience can involve the amount
of experience, time spent to gain a certain experience, and the type of experience.
The level of specificity of work experience can refer to employees’ tasks, job, or orga-
nizational experiences. Research on this model of work experience showed that the
amount of experience and task-level measures of experience were most strongly
positively correlated with job performance [49]. This research suggests that a large
amount of safety-related experiences that are task specific will most likely result in
work behaviors that maximize patient safety. Subsequent research has expanded
on this model and suggested that work experience consists of both quantitative and
qualitative elements that accumulate over the time period during which employees
learn or practice the task. Quantity and quality of work experience, in turn, have been
shown to directly influence employees’ work-related knowledge and skills, motiva-
tion, values and attitudes, and, indirectly, their work performance [50, 51].
In addition to formal experiences gained within the realm of their work, health
care professionals’ may also accumulate personal experiences with medical errors
outside of their work, when they themselves or their family members are in the
patient role. In a study on personal experiences with medical errors among 319 obs-
tetricians and gynecologists, approximately 20% of participants reported that they or
a family member had previously been injured while receiving medical care [52]. More
than half, 56% of all participants, felt free to report and discuss medical errors while
at work. Interestingly, however, participants with personal experiences with medical
errors reported witnessing and reporting medical errors more frequently than partici-
pants without such personal experiences.
In contrast to the concepts of knowledge, skills, and experience, the concept of
competencies has so far received much less research attention in work and organi-
zational psychology as well as in the health care literature. In addition, despite its
widespread popular use, the concept remains relatively ambiguous, ill-defined, and
not very well understood. Some researchers have characterized competencies as a
combination of knowledge, skills, abilities and other individual difference charac-
teristics [53]. However, other researchers have defined competencies as synonymous
with broad sets of work-relevant behaviors. The latter group of researchers has propo-
sed an empirically validated competency framework with eight overarching behavi-
oral dimensions, most of which appear to be of relevance to patient safety behaviors
and outcomes. Specifically, the “Great Eight” competencies are [54]:
1. Leading and deciding: this competency involves taking control, guiding and influ-
encing others, and taking responsibility (e.g., for patient safety outcomes in one’s
organization or unit).
2. Supporting and cooperating: this competency involves supporting others, showing
respect for others, and working effectively with individuals and teams (e.g., in
order to ensure high levels of patient safety).
3. Interacting and presenting: this competency involves communicating, persuading
others, and networking effectively (e.g., to promote the importance of patient
safety in the workplace).
4. Analyzing and interpreting: this competency involves clear thinking, grasping

complex problems, learning quickly, and applying knowledge to new problems
(e.g., to avoid threats to patient safety and the occurrence of harmful incidents).
5. Creating and conceptualizing: this competency involves seeking out learning
opportunities, being creative and innovative, and supporting and driving
change (e.g., to improve the patient safety culture of the team or organization).
6. Organizing and executing: this competency involves planning, organizing, and fol-
lowing directions and procedures (e.g., complying with directions and following
procedures to maintain patient safety).
7. Adapting and coping: this competency involves dealing successfully with changes
and coping well with stressors, changes, and setbacks (e.g., coping successfully
with errors and harmful incidents after they have occurred).
8. Enterprising and performing: this competency involves achieving goals, under-
standing work processes, and seeking opportunities for high performance and
advancement (e.g., finding ways to improve already high levels of patient safety
in the organization).
Health care researchers have claimed that the lack of competence is a major contri-
butor to threats to patient safety. Based on interviews with 38 surgeons from three
hospitals, a study on the predictors of surgical errors and adverse events found that
the most common factor that was reported as contributing to these patient safety inci-
dents were surgeons’ inexperience and lack of competence in a surgical task (53% of
incidents), followed by communication breakdowns in the health care team (43%),
and fatigue and excessive workload (33%) [55]. In the health care literature, a number
of studies have examined so-called “patient safety competencies” of health care pro-
fessionals that overlap to some extent with the empirically validated framework pre-
sented above. For instance, one study conducted a systematic review of competency
assessment tools in different patient safety domains, and classified them according
to the “Canadian Safety Competencies Framework” [56]. This framework proposes six
core competencies of health care professionals [57]:
1. Behaviors contributing to a culture of patient safety (largely consistent with the
“Great Eight” competencies 1, 5, and 8).
2. Working in teams for patient safety (largely consistent with the “Great Eight” com-
petencies 2, 3, and 7).
3. Communicating effectively for patient safety (largely consistent with the “Great
Eight” competencies 2 and 3).
4. Managing safety risks (largely consistent with the “Great Eight” competencies 1, 5,
6, 7, and 8).
5. Optimizing human and environmental factors (largely consistent with the “Great
Eight” competencies 1, 4, 5, 6, 7, and 8).
6. Recognizing, responding to, and disclosing adverse events (largely consistent
with the “Great Eight” competencies 1, 4, and 7).
The above list of patient safety competencies has so far only been employed in a study
with newly registered health care professionals who self-assessed their competencies
as well as their confidence with regard to these competencies [58]. With regard to the
competencies “adapting and coping” (Great Eight) and “recognizing, responding to,
and disclosing adverse events” (patient safety competencies), a study with 129 nurses
reported that these health care professionals indicated that they possess a number of
competencies that they employ in the aftermath of an error [59]. Specifically, nurses
reported that the competencies “accepting responsibility and solving problems” led
to positive changes in practice after an error, whereas the competencies “distancing
and self-controlling” were associated with defensive changes, particularly with a ten-
dency not to disclose errors.
3.4 Decision making
In contrast to cognitive ability, decision making is a more or less conscious cognitive

process that results in the selection of an opinion or behavior from a pool of alterna-
tive opinions and behaviors. Decision making is a central psychological process in the
everyday work of health care professionals, therefore, it has critical implications for
health care practice and patient safety [60]. The reason for the importance of decision
making in the health care domain is that decisions are often made under conditions of
uncertainty and ambiguity as the health outcomes of most treatments cannot be deter-
mined with absolute certainty. However, many patients have the unrealistic expecta-
tion that health care professionals’ decisions are highly reliable and always correct,
whereas all health-related decisions are, in fact, probabilistic and some decisions
based on general knowledge may not benefit individual patients. In addition, diffe-
rent health care professionals often disagree about the optimal treatment for a specific
patient. Nevertheless, health care professionals have to make a decision regarding the
appropriate diagnosis for a patient and which treatment they will recommend.
Not only the decision making processes of health care professionals are relevant
to patient safety, other stakeholders also have to make decisions that may impact
the diagnosis, treatment, treatment outcomes, and quality of care of patients. First,
patients themselves have to make a decision whether to seek advice from one or more
health care professionals. Increasingly, both patients and health care professionals
participate as equal partners in the decision making process with regard to the choice
of the treatment plan (i.e., shared medical decision making). Second, health care
managers, insurance companies, and policy makers have to make decisions regar-
ding staffing levels in hospitals, which treatments they will pay for, and what health
care policies they should promote to the public.
Research in the field of psychology has investigated how people make decisions
and what factors influence the decision making process and the quality of outcomes
of decisions.
For instance, researchers have examined how individual factors (e.g., reasoning
ability, emotions, preferences, and values), situational factors (e.g., group norms),
and interactions of these factors influence decision making processes and outcomes.
Generally, research on decision making has distinguished between logical or statisti-
cal (probabilistic) decision making and heuristics-based decision making. The former
type of decision making is more likely to take place when people have a lot of back-
ground information available and when they have the possibility and resources to
carefully evaluate all potential outcomes of a decision in terms of their expected costs
and benefits (i.e., rational choice). The latter type of decision making is more common
in situations with high time pressure, information overload, as well as high ambiguity
and uncertainty. These characteristics are common in health care. Thus, the role of
heuristics in decision making will be further explained in the next section.
3.4.1 Heuristics and biases in decision making
Psychological research on heuristics assumes that, over the course of thousands of

years of evolution, people have developed a number of cognitive shortcuts to deal with
complex environments and resource scarcity (e.g., scarcity of time, information, and
energy) [61]. Heuristics are simple and efficient decision rules that can be both conscious
and unconscious. They help people make fast decisions under resource constraints
and in complex situations that do not allow for collecting all existing information as
well as a lengthy and completely rational evaluation of multiple alternative outcomes.
Most heuristics involve focusing on only one part of a complex problem that needs to be
solved and ignoring other aspects. For instance, physicians may prescribe a medicine
from a particular pharmaceutical brand to a patient because they associate the brand
in general with high quality instead of undertaking a detailed assessment of the brand’s
different pharmaceutical products. Thus, the use of this heuristic saves the physician
effort and time. Several other examples of health care professionals making decisions
based on their “gut feelings” exist. While these heuristics are often useful and efficient,
sometimes they can lead to errors in decision making. In other words, the outcomes
of decisions may then deviate from outcomes of decisions that were based on logical
thinking, probabilistic reasoning, and rational choice. These errors are called biases in
decision making research. Importantly, even though heuristics may sometimes lead to
biases, they are usually efficient and good enough for most decisions under resource
constraints and ambiguity. In fact, research in psychology has shown that [61]:
1. With gains in experience accumulated over time, employees and organizations
frequently improve in their use of simple heuristics.
2. Ignoring some pieces of information of a larger problem may often lead to better
decisions than adding and weighting all available information.
3. Associating logical and statistical decision making with correct and rational rea-
soning on the one hand and heuristics-based decision making with erroneous
intuitions and irrationality on the other hand is wrong, because heuristics can
lead to better decisions even though they process less information than logical
and statistical decision making.
4. The effectiveness of heuristics depends on the characteristics of the environment
in which decisions are made; heuristics often lead to better decision outcomes
in unstructured, uncertain, and ambiguous contexts (e.g., many modern
organizations).
Five very common heuristics that can be part of people’s decision making processes
may lead to better decisions or introduce biases:
1. Framing the problem: the framing of a specific decision task can impact on decis-
ion making. For instance, decisions in health care could be influenced by whether
outcomes are framed in terms of the preventing the likelihood of adverse events
or even deaths (losses) or in terms of improving the quality of patient care or
saving lives (gains). When losses are emphasized, people tend to take more risks
in order to avoid or alleviate losses. In contrast, emphasizing gains makes people
more risk averse, as they want to sustain what they have. In a similar vein, the so-
called “affect heuristic” makes positively framed messages more persuasive than
messages that contain only factual or negatively framed information.
2. Using information: people are more attentive to information that is easily availa-
ble, including data in their immediate environment or memories that can be easily
retrieved (e.g., emotional or personally relevant memories) (“availability bias”).
In addition, people pay more attention to information that presents themselves
in a positive way (“self-serving bias”) and to information that provides support to
one’s own knowledge and opinion, whereas opposing views are frequently dis-
counted (“confirmation bias”).
3. Representativeness: people use previously established categories to make decisi-
ons, and something has a high representativeness for a category if it is very similar
to the prototypical content of that category. Using the “representativeness heuris-
tic” may lead people to focus on the uniqueness of someone or something and to
ignore its base rate, or occurrence in the population.
4. Problems of judgment: to avoid information overload, people have to filter, prio-
ritize, and categorize different pieces of information that they encounter in their
daily lives. While these processes allow people to make efficient decisions under
complexity, ambiguity, and uncertainty, it may also result in biased judgments due
to overconfidence (i.e., unrealistic optimism in the face of uncertainty) or insuffici-
ent anchoring adjustment (i.e., failure to adapt to changes in the environment over
time once an initial decision has been made).
5. Post-decision evaluation: the so-called “self-enhancement” bias describes
people’s desire to maintain high levels of self-esteem and leads them to disregard
information that might make them or their decisions and behaviors look unfa-
vorably (e.g., errors). This may lead to the “fundamental attribution error”, or
the tendency to attribute positive outcome to one’s own behaviors and negative
outcomes to external factors (e.g., environmental constraints, bad luck). While
these biases guard against loss of self-esteem and may help persistence in chal-
lenging situations, they might also reduce learning about failures and errors and
reduce people’s willingness to correct errors and misguided actions. In addition,
most people have an innate desire to feel that they are in control over events, the
environment, and their lives in general. This may lead them to attribute more
control over events than they actually have. This bias could lead to an underesti-
mation of the risks associated with decisions and behaviors.
3.4.2 Shared decision making
Traditionally, important medical decisions were made solely by experts (i.e., health
care professionals) without any involvement of lay people (i.e., most patients). The
main reasons for this decision making monopoly were the assumed authority as well
as expert knowledge and skills of the health care professionals. The notion of shared
decision making is a relatively new and rapidly emerging paradigm in health care
practice that may cause various concerns and skepticism both among health care pro-
fessionals as well as patients [62]. Shared decision making describes a process during
which patients and health care professionals together judge multiple available alter-
native options before making a joint medical decision. The process of shared decision
making involves both parties acknowledging at the beginning that, for many medical
problems, uncertainty exists about the right diagnosis and optimal treatment options.
This opens a two-way discussion and exchange of important personal and medical back-
ground information. Health care professionals educate patients about the possible risks
and benefits of each option relevant to the decision. They may also prepare decision
aids or exercises to help patients evaluate the risks and benefits as well as potential
consequences of different options and decisions. In the decision making process,
patients can share their preferences, expectations, and concerns with their health
care professional, many of which would otherwise be unknown to the professio-
nal. Shared decision making helps integrate these factors into the decision making
process.
After the exchange of relevant personal and medical information between patients
and health care professionals as well as diagnostic assessments and the use of deci-
sion making aids, the health care professional, the patient, and relevant others (e.g.,
the patient’s family members) attempt to come up with a mutual decision through
open and critical discussion. Some researchers have recommended that shared decis-
ion making is most effective when multiple options exist and health care professionals
cannot identify a single best option themselves [62]. Conversely, other researchers
have suggested using shared decision making in any case, as otherwise patients may
decide to boycott their health care professional’s solitary decision and effectively do
nothing to improve their health status. Importantly, while most patients are interested
in participating in medical decision making, for various reasons some patients are
not interested in participating, and thus health care professionals should take into
account individual differences in patients’ preferences for shared decision making.
Importantly, medical decisions may not only be shared between patients and
health care professionals, but they may also be shared in the context of multidisci-
plinary health care teams. So far the processes and outcomes of decision making in
such teams are not well documented and ideal structures for effective team decision
making are not well understood. However, a recent review of the literature on decis-
ion making in surgical oncology and the systems approach to surgical performance
provided a preliminary theoretical framework for decision making in health care
teams [63]. In a nutshell, the researchers suggested that decision making in teams is
influenced by and could be strengthened by optimizing:
1. Technical factors: this includes all available information about patients, robust
equipment, expert reviews of medical information, and the recording of the
team’s decisions.
2. Non-technical factors: this includes regular attendance of team members at mee-
tings, leadership quality, teamwork quality, open discussions, agreement on deci-
sions, and communication with patients and primary care.
3.5 Work motivation
Motivation is one of the central concepts in the field of psychology, and work and orga-
nizational psychologists have always been interested in understanding, predicting,
and improving employees’ levels of motivation at work. Broadly defined, motivation
refers to the various factors and processes that predict and explain intraindividual
(or “within-person”) changes and interindividual (or “between-person”) differences
in the direction (i.e., does the effort expended lead to beneficial outcomes for the
organization or not), intensity (i.e., how hard does someone try), and persistence
(i.e., how long does someone maintain effort expenditure) of effort that is invested
to attain work-related or organizational goals [64]. In terms of health care employees’
motivation to engage in behaviors related to patient safety, researchers and practitio-
ners need to ask whether employees’ efforts at work contribute to patient satisfaction,
how much effort they invest in maintaining and enhancing patient safety, and how
long they are willing to invest effort on behalf of patients’ safety.
How does an employees’ motivation to engage in safety-relevant work behaviors
relate to safety performance? A relatively simple equation that visualizes the impor-
tance of safety motivation for safety performance is [7]:
Safety performance = (safety ability × safety motivation)

− situational constraints
This equation indicates that if an employees’ ability to maintain high levels of

patient safety is low (e.g., due to inadequate training), employees have to expend
more safety-related effort (i.e., higher safety motivation) to reach relatively high levels
of safety performance. In contrast, if employees’ motivation to behave in ways that
maintain patient safety is low, the influence of their safety-relevant ability on safety
performance is weakened. In addition, situational constraints such as equipment
errors, an unfavorable safety culture, or lack of colleague and supervisor support
may additionally weaken the interactive effects of safety ability and safety motiva-
tion on safety performance. A meta-analysis of antecedents of safety-related beha-
viors and outcomes at work found that safety motivation is closely related to safety
behaviors and, together with safety knowledge, one of the best predictors of safety
behaviors [44].
3.5.1 Need theories of motivation
In the following section, a number of work motivation theories that are potentially
relevant to patient safety processes and outcomes will be described and explained.
Between the beginning and the middle of the 20th century, early psychological theo-
ries of motivation assumed that employees have inborn tendencies, such as instincts
and needs that energize work behavior. Until today, Abraham Maslow’s hierarchy of
needs framework remains one of the most widely known examples of these theories
that, even though they have not received much empirical support, are of historical
value. Maslow’s hierarchy of needs model proposed that five universal human needs
exist (moving from lower-order to higher-order needs with work-related and patient
safety-related examples in parentheses):
– Physiological needs/sustenance (e.g., base salary, no physical harm)
– Security needs/stability (e.g., pension plan, trust in health care provider)
– Belongingness needs/friendship (e.g., supportive coworkers, recognition for
safety performance)
– Esteem needs/status (e.g., job title, unit safety representative)
– Self-actualization needs/achievement (e.g., achieving high levels of patient safety)
According to the hierarchy of needs model, a lower-order need has to be satisfied

before the next higher need becomes salient to the person. While the model did not
receive empirical support, its core ideas or stages may be relevant to patient safety
research. For instance, physiological needs and security needs are important con-
cerns of patients that health care professionals should be aware of in their work.
Belongingness and esteem needs may play a role in patient safety in that they point
to potential incentives for safety work behaviors. Specifically, employees who help
maintain high levels of patient safety may be rewarded with social recognition from
their colleagues as well as status-related rewards from their organization (e.g., safety
representative). Finally, self-actualization needs are a potentially very important
intrinsic motivator for safety behaviors. Specifically, employees may perceive the
maintenance and enhancement of patient safety as both a personal challenge and
ambitious goal to achieve as well as a deeply satisfying and idealistic form of work
behavior.
3.5.2 Expectancy theory
Compared to the early content and need theories of work motivation, contemporary
psychological work motivation theories focus more on the motivation process than on
the content of motivation. One of the most prominent and well-established process
theories of work motivation is expectancy theory, also call valence-instrumentality-
expectancy (VIE) theory [65, 66]. Figure 3.2 shows a simplified illustration of the
factors and processes involved in expectancy theory.
The theory proposes that the extent to which employees are motivated to invest
individual effort at work is influenced by the multiplicative combination of three per-
ceptual factors:
1. Expectancy: the individual employee’s perception that a strong positive rela-
tionship exists between his or her individual level of effort and the resulting
individual performance (e.g., safety motivation → safety performance).
2. Instrumentality: the individual employee’s perception that a strong positive rela-
tionship exists between his or her level of performance and an organizational
reward (e.g., safety performance → social and organizational recognition).
3. Valence: the individual employee’s perception that a strong positive relation-
ship exists between the organizational reward and his or her personal goals. In
other words, how attractive is the organizational reward to the employee? (e.g.,
social and organizational recognition → feelings of personal satisfaction and
achievement).
Personal
Rewards for
Safety-related Safety goals related
safety
effort performance to patient
performance
safety
Perception of the Perception of the Perception of the

effort-performance performance-reward reward-personal
relationship relationship goal relationship
(expectancy) (instrumentality) (valence)
Fig. 3.2: Illustration of expectancy theory; adapted from [7]

For instance, a nurse working in a community hospital may be more motivated to

invest effort into work goals and behaviors that contribute to patient safety (e.g., hand
hygiene in situations with high time pressure) if the following conditions are satisfied:
1. Expectancy: he believes that his efforts to wash hands can be realized in the work
situation (e.g., hand hygiene equipment and time to clean hands are available).
2. Instrumentality: he believes that his colleagues, supervisors, and the organization
value and reward safe work behaviors (e.g., he may receive positive supervisor
feedback).
3. Valence: he personally believes that safe work behaviors are important and
appreciates positive feedback on his work behaviors.
3.5.3 Goal setting theory
Another widely researched and well-established process theory of work motivation

is goal setting theory. According to this theory, explicit work goals (e.g., safety goals
regarding the number of errors or harmful incidents per month) influence employees’
motivation such that employees who have specific and difficult goals perform better
than employees who do not have goals at all or who have “do your best goals” [64, 67].
Goals can be considered specific, for instance, if expected performance can be quan-
tified for a specific time-period in the future. Goals are difficult or challenging if they
stretch employees abilities to some extent, while they should still be achievable by
employees. Goal setting theory argues that specific and difficult goals influence the
three components of employee motivation, that is, direction, intensity, and persis-
tence. In particular, specific and difficult goals focus employees’ attention and beha-
vior on a standard that they should attain (i.e., direction), activate employees to
expend high levels of effort (i.e., intensity), and help employees maintain high levels
of effort over time (i.e., persistence). Another explanation for the motivating effects
of specific and difficult goals is that people with such goals are more likely to develop
relevant and appropriate strategies for attaining their goals.
Importantly, specific and difficult goals are only effective if employees accept
these goals (e.g., if the goals are not self-set but are assigned to employees by their
supervisors or the organization) and if employees’ subsequent commitment to the
goals is high. Research has shown that participation in goal setting (e.g., together
with one’s supervisor) does not necessarily lead to better performance and that goals
set by someone else in the organization can be quite effective if the reasons for the
goals are well explained to employees. However, if goals cannot be self-set by emplo-
yees, participation in goal setting may increase employees’ goal acceptance and
commitment.
Health care organization could apply the principles of goal setting theory
to increase health care professionals’ safety motivation and performance. For
instance, annual performance reviews could be used to come to an agreement

between individual employees and their supervisors regarding the expected safety
outcomes for the next year. On a broader scale, health care units or organizations
could set specific targets for safety performance, such as maximum number of
errors, harmful incidents, and patient complaints, or minimum levels of patient
satisfaction. According to goal setting theory, specific and difficult safety goals
set for individual health care employees, teams, and even the organization as a
whole should lead to better safety performance because employees will be more
motivated to achieve such goals, as well select and employ better safety-relevant
work strategies.
3.5.4 Self-efficacy
Social cognitive theory is a prominent psychological theory that explains the recipro-
cal relationships between personal characteristics, people’s behavior, and people’s
physical and social environment [68]. An important motivational concept that is
based on social cognitive theory is self-efficacy, or a person’s belief in his or her ability
to perform a specific task or to reach a specific goal [68, 69]. In other words, work
self-efficacy is an individual difference characteristic that is related to employees’
confidence that they can achieve certain outcomes in the work context. For instance,
health care professionals might differ with regard to their safety-related self-efficacy,
that is, their personal confidence in their ability to carry out their work in a way
that ensures high levels of patient safety. Self-efficacy is a motivational concept
and, consistently, numerous studies have shown that high levels of task-specific
but also generalized self-efficacy are associated with higher levels of work perfor-
mance [70]. Thus, one way to increase individual employees’ safety performance
may be to enhance their safety-related self-efficacy through training and other more
informal interventions.
According to social cognitive theory, employees’ self-efficacy can be increased by
addressing four distinct mechanisms or antecedents of self-efficacy [69]:
1. Mastery experiences: employees experience mastery when they are successfully
dealing with and completing a challenging task or job assignment.
2. Vicarious learning: vicarious learning takes place when employees observe
someone else who is similar to them perform and succeed at a challenging task or
job assignment.
3. Social persuasion: social persuasion involves employees being encouraged by
relevant others such as colleagues and supervisors who express confidence in
employees’ abilities to accomplish a challenging task or job assignment.
4. Physiological states: feeling positive and energetic compared to distressed and
worn-out signals to employees that they have the ability to perform and succeed
at a challenging task or job assignment.
In the context of health care work, practitioners could increase health care professio-
nals’ safety-related self-efficacy and subsequent safety performance by:
1. Mastery experiences: supervisors or trainers could provide employees with more
easily attainable subgoals or realistic milestones that need to be achieved as
well as frequent support, encouragement, and feedback. These strategies allow
employees to quickly experience mastery and success in safety-relevant tasks.
2. Vicarious learning: on the job or in training, employees should be paired up with
successful role models or mentors that demonstrate high levels of safety perfor-
mance and positive safety attitudes and motivation.
3. Social persuasion: supervisors and trainers should encourage and motivate emplo-
yees to try out safety-relevant tasks and exercises and engage in safety-relevant tasks,
for instance by highlighting their safety-relevant knowledge, skills, and abilities.
4. Physiological states: it is important to reduce stress and negative physiological
and emotional states in the health care work environment because these factors
may detract employees’ attention from the safety-relevant goals, tasks, and
behaviors.
Related to the concept of and processes involved in self-efficacy, and potentially impor-
tant for increasing safety performance of employees, are the “Pygmalion effect” and
the “Galatea effect” [71, 72]. Both techniques have been shown to lead to higher levels
of performance in the work context. The Pygmalion effect describes the motivatio-
nal and performance effects of a self-fulfilling prophecy. For instance, the Pygmalion
effect hypothesis predicts that new supervisors who are told that the employees that
they will work with in the future have demonstrated particularly high levels of safety
performance in the past (no matter whether this is the truth or not) will implicitly
encourage these employees to engage in these behaviors. These implicit motivational
processes should lead to higher safety performance.
The Galatea effect is related to the Pygmalion effect phenomenon. The Galatea
hypothesis predicts that if supervisors (or the organization) explicitly communicate
high expectations to their employees that may or may not be based on actual behavi-
ors (e.g., “We believe that you show exceptionally high levels of safety performance
and we expect that also in the future you will prioritize patients’ safety in everything
you do at work”), it will lead to a higher performance that is consistent with the com-
municated expectations. Thus, whereas the Pygmalion effect does not involve com-
municating high performance expectations to employees, the Galatea effect uses
social persuasion processes to motivate employees.
3.5.5 Reinforcement theory
Reinforcement theory became a dominant approach in the field of psychology and

especially in research on human and animal learning in the early 20th century as
part of the emerging behaviorist movement. According to reinforcement theory,

employees’ motivation to engage in or to show specific work behaviors is a func-
tion of the consequences of these behaviors [73]. “Reinforcers,” such as rewards and
punishments, are immediate consequences of behavior that increase or decrease the
likelihood that the behavior will be repeated in the future. Based on reinforcement
theory, the technique of “operant conditioning” involves rewarding desired behavi-
ors and punishing undesired behaviors to change the likelihood of their occurrence
in the future [73]. Numerous laboratory studies have provided empirical evidence for
the propositions of reinforcement theory, including the finding that operant condi-
tioning is effective in modifying animals’ and people’s behavior in the short-term.
However, reinforcement theory is limited in its value for practical applications in
work contexts, because it ignores cognitive factors (e.g., goals, beliefs, and expec-
tations) and emotional states, which are undoubtedly important in the context of
employee motivation.
Nevertheless, possible applications of some of the ideas of reinforcement theory
for patient safety are to reward positive safety-related behaviors of health care profes-
sionals. Rewards should be given soon after employees have shown the desired beha-
vior and not days or weeks later. Money and other material rewards (e.g., prizes) are
generally strong reinforcers of behavior, but rewards in the form of social recognition
and acknowledgement, for instance by colleagues, supervisors, or the organization
(e.g., rewarding an employee by making her a safety representative), may be more
suitable reinforcers of safety behavior in health care. However, it is not recommended
that unsafe behaviors are punished immediately or after time has passed, because
punishment, although effective in the short-term, may lead to negative feelings
toward supervisors and the organization as well as attempts of retaliation.
3.5.6 Control theory
Control theory is a well-established theory of motivation and employee self-

regulation (i.e., changing one’s behavior based on feedback from others and the
environment) [74]. Control theory argues that work outcomes are the result of emplo-
yees’ behavior in combination with external factors from the work environment.
Employees more or less continuously observe information about the outcomes of
their behavior. The monitored information may be self-generated or come from
other people or things in the environment. Next, employees compare the perceived
outcomes of their own behavior to certain internalized goals or standards, which
may have been originally set by either themselves or others. If no discrepancy exists
between the perceived outcome and their internalized standard, employees will dis-
continue showing the behavior because their goal has been achieved. However, if a
discrepancy exists between their perceived outcome and their internalized standard,
employees will adjust or change their behavior accordingly [75]. Thus, the feedback
External
Safety factors
behavior
Comparison Safety
to standard outcomes
Perception
of safety
outcomes
Fig. 3.3: Control theory
process postulated by control theory influences later behavior. A simplified version

of control theory is shown in Fig. 3.3.
The propositions of control theory have potential practical implications for main-
taining and enhancing patient safety in health care contexts. According to the theory,
patient safety is the result of both employee behavior as well as external factors.
Employees monitor the patient safety outcomes that they are partially responsible for
and compare these outcomes to their internalized standards. One possibility for inter-
ventions may be to change the internalized standards of employees to reflect higher
levels of patient safety. If the comparison between the patient safety outcome and the
internalized standard results in a discrepancy, control theory argues that employees
will be motivated to adapt or change their behavior to reach the established safety
standard in the future. Thus, another intervention possibility is to help employees
adapt or improve their safety-relevant behaviors, for instance, by providing them with
information, mentoring, or access to training on patient safety. Finally, organizations
should ensure that external constraints of positive patient safety are minimized and
external facilitators of patient safety are maximized. This will enable employees to
have a stronger influence on patient safety outcomes through appropriate safety
behaviors.
3.5.7 Equity theory and organizational justice
Work and organizational psychologists have proposed that employees’ perceptions of

equity, inequity, and justice in the workplace are linked to work motivation and work
performance. According to equity theory, employees’ motivation to engage in certain
work behaviors is determined by the result of a subjective comparison between two
components. The first component is employees’ perceived ratio of (a) the rewards and
benefits that they get from their job (e.g., salary, recognition, interesting work) and (b)
the things that they invest into their work (e.g., effort, time). The second component
is employees’ perceived ratio of the (a) inputs and (b) outcomes of a relevant other
person (e.g., a colleague in the same unit) [76].
Equity refers to a positive subjective state that results from a subjectively fair
match between one’s own input-output ratio and the input-output ratio of the other
person. In contrast, inequity describes a negative subjective state that results from
the feeling that one is putting more into their job than they get out of it compared to
relevant others (who may be getting more out of their job than they put in). According
to equity theory, the feeling of inequity motivates employees to correct this negative
state by changing their inputs (e.g., investing less effort), changing their outcomes
(e.g., asking for and obtaining a pay raise or a different job status), changing their
perceptions of their own or the other person’s ratio between inputs and outcomes,
choosing a different person to compare themselves with, or they could leave their
field of work altogether [76].
With regard to patient safety, employees may perceive their personal investment
into patient safety at work and what they get in return from the organization unfa-
vorable compared to their colleagues in the same work unit or compared to colle-
agues in other units. It is important that health care organizations are aware of the
issue of perceived inequity and ensure that employees will not react by reducing their
patient safety engagement based on perceptions of inequity. For instance, organiza-
tions could attempt to increase employees’ perceptions of their personal outcomes
of engaging in patient safety (e.g., by providing them with more rewards and recog-
nition). Another possibility may be that organizations provide individual employees
with more appropriate referents for comparison. For instance, organizations could
highlight the personal commitment and sacrifice (i.e., high investment but low expec-
tations of rewards) of employees with high levels of patient safety engagement.
More recent research in work and organizational psychology has expanded the
field of organizational justice beyond equity theory by distinguishing between four
central dimensions of organizational justice perceptions of employees [77, 78]:
1. Distributive justice: employees’ perceptions of the fairness of the level of outco-
mes that they and others at work receive (e.g., rewards for patient safety or care
quality).
2. Procedural justice: employees’ perceptions of the fairness of the process that is
used to distribute outcomes (e.g., the transparency of the process that is used in a
hospital to allocate rewards for high levels of patient safety or quality of care).
3. Interactional justice: employees’ perceptions of the fairness with which they are
treated (e.g., supervisor or management reactions to errors that were not under the
individual employees control).
4. Deontic justice: employees’ perceptions of what the right thing is to do for them-
selves and the company (e.g., establishing and maintaining a culture of safety,
disclosing errors to supervisors and the patient).
3.5.8 Social identity theory
The topic of work motivation has also been explored from the perspective of social
identity theory [79–81]. The central idea of social identity theory is that people’s mem-
berships in social groups (e.g., the occupational group of nurses, the group of health
care professionals, or the group of employees working in this hospital) influence their
self-concept, that is, how they think about and view themselves. Social identification,
then, is the subjective feeling of belongingness to a group as well as the description
and definition of oneself as a group member (e.g., “I am part of this hospital”). The
process of social identification involves that the characteristics that are typical of the
group and other group members (e.g., a strong commitment to patient safety) are
ascribed to oneself and internalized. Employees’ social identities help explain the
effects of group membership on employees’ feelings, attitudes, and behaviors. Spe-
cifically, the more employees identify with a social group, the more likely they are to
perceive, feel, and behave in ways that are consistent with the group’s values, norms,
and goals. For instance, physicians and nurses who identify strongly with their occu-
pations are more likely to endorse values such as patient safety and high quality care
and act accordingly in their everyday work. A model of how social identification may
influence health care professionals’ safety motivation and performance is shown in
Fig. 3.4 [79].
Figure 3.4 suggests that social identification may influence safety performance
in the workplace in three consecutive steps. First, the more health care professionals
identify with their occupation, employer, or work unit, the stronger their motivation
will be to behave in ways that are consistent with the goals and norms of these social
groups. The strength of this effect is influenced by the extent to which a given social
identity is salient to employees. For instance, if a different social identity is salient
(e.g., member of the group of female employees, member of a sports club), health
care employees’ occupational identity is less likely to influence their social motiva-
tion. Second, employees’ motivation to behave consistently with their occupational
groups’ goals should lead to higher safety motivation, that is, the willingness to
expend effort in safety-related activities. Again, this effect is qualified: employees’
Perceptions of
Social Control over
collective goals
identity safety
and interests
salience performance
related to safety
Social Social Safety Safety

identification motivation motivation performance
Fig. 3.4: Social identity model of work motivation and performance; adapted from [79]
perceptions of the strength of their social groups’ collective goals and interests (e.g.,
goals and interest related to patient safety) determines the strength of the associa-
tion between general social motivation and safety motivation. If employees perceive
strong collective goals and interests related to patient safety, the effects of a general
willingness to act consistently with group goals and norms will lead to higher safety
motivation. In contrast, when employees perceive low levels of collective goals and
interests related to patient safety, they are more likely to express their social moti-
vation in other ways than safety motivation. Finally, the model suggests that safety
motivation has a positive effect on safety performance, given that employees have
moderate or high levels of control over safety performance. If, however, employees’
control over safety performance is low or non-existent (e.g., due to strong regulati-
ons), their safety motivation cannot impact on their safety performance.
3.5.9 Relational theory of work motivation
A more recently developed theory of work motivation emphasizes employees’ pro-

social (or other-oriented) motivations and how employees and their work tasks
relate to other people in the work context, especially people who benefit from their
work [82, 83]. This theory has clear implications for the health care context and the
topic of patient safety, as most of the work of health care professionals has impor-
tant implications for patients and their health. According to the relational theory of
work motivation, employees are especially motivated to show high levels of effort
at work if they perceive that other people (e.g., patients, patients’ family members)
benefit in meaningful ways from the work they do. This perceived job characteristic
is called “task significance.” The relational theory of work motivation has received
empirical support in several studies, including research conducted in the health
care context on the importance of hand hygiene in order to prevent the spreading
of diseases.
The health care study proposed that motivational messages about hand hygiene
are more effective in the health care context if they highlight the consequences of
hand hygiene for patients compared to highlighting the consequences for health care
professionals themselves [84]. The reason for this assumption was that health care
professionals tend to be overly confident about their own immunity, whereas they are
usually more concerned about other patients’ immunity. In two experiments carried
out in a hospital in the United States, researchers compared the effects of motiva-
tional hand hygiene signs which focused on either personal consequences (i.e.,
“hand hygiene prevents you from catching diseases”) or consequences for patients
(i.e., “hand hygiene prevents patients from catching diseases”) [84]. Subsequently,
in the first experiment, the researchers monitored dozens of soap dispensers in the
hospital to measure the amount of soap and hand sanitizing gel used. In the second
experiment, the researchers secretly observed the health care professionals hand
hygiene behaviors. The results of both field experiments showed that reminders of
consequences for other people, in this case patients, have a greater influence on
patient safety behaviors of health care professionals than reminders of personal con-
sequences. Interestingly, these effects on behavior resulted from only changing one
word in motivational messages displayed in the hospital (“you” vs. “patients”). These
findings suggest that, in order to increase safety motivation and behavior among
employees, health care organizations could emphasize the importance of patients’
health using signs, messages, and other reminders.
A version of the relational theory of work motivation that has been adapted to the
context of health and patient care is shown in Fig. 3.5. According to the model, objec-
tive task significance, or the magnitude, scope, and frequency of the impact emplo-
yees’ work has on patients, will positively influence employees’ perceived impact on
patients and, in turn, the motivation to make a prosocial difference at work (e.g., by
always ensuring high levels of patient safety). The influence of employees’ percei-
ved impact on patients and their motivation to make a prosocial difference will be
particularly strong if employees’ are highly committed to their patients. The motiva-
tion to make a difference will subsequently positively influence employees’ levels of
work effort, persistence, and helping behaviors directed at patients. The motivational
factors may then positively contribute to patient safety.
Another important factor that is proposed to influence prosocial motivation is
employees’ level of contact with patients. Specifically, the frequency, duration, phy-
sical proximity, depth, and breadth of contact with patients will positively influence
employees’ perceived impact on patients, as well as their commitment to patients.
The theory also argues that the influence of contact with patients on commitment
to patients should be particularly strong if employees possess a lot of positive social
information about them (e.g., personal and medical backgrounds) as compared to
unfavorable social information.
Impact of Perceived
work on impact on
patients patients
Motivation Effort,
to make a persistence,
difference and helping
Contact
Commitment
with
to patients
patients
Information
about
patients
Fig. 3.5: Relational job design and motivation in the health care context; adapted from [83]
3.6 Personality 45
3.6 Personality
Employees’ personality characteristics are of significant interest to psychologists, and

especially work and organizational psychologists, because they have been shown to
predict a broad range of behaviors and important life outcomes, including subjec-
tive well-being, job satisfaction, different forms of work performance, and long-term
career success [85–88]. Personality characteristics are broadly defined as the typical
or characteristic ways in which a person responds to situations, and are construed
as relatively stable across time and different situations. In others words, personality
characteristics describe an employee’s usual way of responding to situations, such
as work assignments or interpersonal interactions at work (e.g., communicating with
colleagues or patients). However, it is important to note that personality does not
always translate into behavior, as unusual circumstances may cause an employee to
show behaviors that differ from his or her typical way of acting and responding.
A widely-researched and well-validated model of personality is the five factor
model of personality, sometimes also called the “Big Five,” a taxonomy of five broad
personality factors that were derived from lexical analyses [89]:
1. Conscientiousness: conscientious people are responsible, persistent, planful,
achievement oriented, and show high levels of self-control.
2. Extraversion: extraverted people are sociable, assertive, talkative, and energetic.
3. Agreeableness: agreeable people are friendly, cooperative, trusting, and likeable.
4. Emotional stability (or neuroticism): emotionally stable people are secure, calm,
and have low levels of anxiety, depression, and impulsivity.
5. Openness to experience: people with high levels of openness to experience
are interested in novel aspects of life, curious, imaginative, and independent
thinkers.
Out of these five characteristics, conscientiousness and, to some extent, emotional

stability have been shown to be the best predictors of work performance in a broad
variety of different jobs and occupations [90, 91]. While these two personality charac-
teristics appear to generally predict work performance, the other personality charac-
teristics are predictive of work performance in specific jobs. For instance, extraversion
is an important characteristic of successful entertainers and fitness trainers, whereas
agreeableness is an important characteristic in jobs that involve teamwork and custo-
mer service interactions. Importantly, personality is a better predictor of work perfor-
mance in jobs that offer employees a great deal of personal discretion and autonomy.
In contrast, personality characteristics are less likely to affect work performance in
jobs that are highly regulated (e.g., assembly line work).
Work and organizational psychologists have suggested that personality assess-
ments could be useful to improve safety in the work context [44]. Specifically, these
researchers argued that employees could be selected based on measures of conscien-
tiousness to increase safety motivation and safety knowledge in work teams. Results of
their meta-analysis indicated that, across a broad range of jobs, highly conscientious
employees were more likely to possess high levels of safety motivation and safety know-
ledge that, in turn, predicted these employees’ safety behaviors and objective outco-
mes, such as accidents and injuries. Conscientiousness as well as emotional stability
also appear to be the most important personality predictors of work behaviors related
to maintaining patient safety. Conscientious health care professionals should be more
likely to pay attention to and comply with safety procedures, as they are aware of their
responsibility for patients’ health and safety. Emotionally stable employees should
be able to maintain calm and be in control in stressful and uncertain work situations,
which should help them carry out relevant safety procedures even when under pres-
sure. Finally, agreeableness may be an important characteristic of health care professi-
onals dealing with patients and patients’ concerns, as they are friendly and trustworthy.
However, a potential disadvantage of high levels of agreeableness may be that the need
to get along with others and to be liked, this may hinder their ability to engage in dif-
ficult yet necessary behaviors, such as disclosing errors to supervisors and patients.
Aside from the dominant five factor model of personality, a number of additi-
onal important personality-like characteristics are frequently investigated in work
and organizational psychology. Two recent and prominent examples are core self-
evaluations and emotional intelligence. Core self-evaluations are a higher-order
personality construct that involves high levels of self-esteem (i.e., a positive attitude
toward one’s self-worth), high self-efficacy, an internal locus of control (i.e., a belief in
one’s ability to influence life outcomes), and high emotional stability [92]. Core self-
evaluations have been shown to positively predict employee well-being, performance,
and career success. They may also constitute an important influence on patient safety
outcomes, consistent with the notion that people who value themselves are also in a
better position to value others, including their patients.
Finally, an emerging construct in psychology is emotional intelligence, or the
ability to understand one’s own and others’ emotions, and to regulate these emotions
in oneself and others [93, 94]. Emotional intelligence is conceptualized as having two
broad dimensions:
1. Intrapersonal intelligence: the ability to understand oneself and to use that know-
ledge about oneself to regulate one’s emotions in accordance with situational
requirements.
2. Interpersonal intelligence: the ability to understand and to regulate other
people’s emotions by interacting with them.
Emotional intelligence may be an important individual difference predictor of patient

safety outcomes. First, interpersonal intelligence may help health care professionals
better understand and interact with their patients, which may enhance patient safety
and prevent potential threats. Second, intrapersonal intelligence may be useful for
health care employees in terms of understanding their reactions to stressful events,
including those that may lead to errors and incidents or threats to patient safety.
A number of studies have attempted to empirically link personality characteristics

and workplace safety. In one stream of the literature, researchers examined associa-
tions between personality characteristics and employees’ tendency to get involved in
accidents themselves. For instance, one study showed that “social maladjustment,” a
personality characteristic related to both low conscientiousness and low emotional sta-
bility, positively influenced employees’ accident proneness [95]. Another study confir-
med that employees’ with low levels of emotional stability were more likely to be invol-
ved in work-related accidents [96]. In another stream in the literature, researchers have
investigated links between employees’ personality characteristics and patient safety-
related behaviors and outcomes. For instance, the results of a study with 46 participants
showed that nurses’ level of agreeableness positively influenced their willingness to
collaborate with their colleagues [97]. This is an important finding as willingness to
collaborate is in turn predictive of high quality care. However, the study also found that
high agreeableness of nurses strengthened the negative impact of negative supervisor
mood on nurses’ willingness to help colleagues. Thus, nurses with high agreeableness
were less likely than nurses with low agreeableness to collaborate if their supervisor
was in a negative mood, possibly, because they did not dare to speak up. Finally, a study
using a sample of 263 nurses in Taiwan explicitly investigated the relationship between
nurses’ emotional stability and patient safety [98]. The researchers argued that nurses
with high levels of emotional stability are less prone to strong emotional reactions and
are more likely to engage in problem-solving behaviors in stressful situations. Consis-
tent with these hypotheses, the results of the study showed that nurses’ emotional sta-
bility positively influenced nurses’ self-reports of patient safety.
3.7 Attitudes and emotions
3.7.1 Attitudes
Attitudes are relatively stable beliefs or opinions about something (e.g., an object or
event). Consistently, job attitudes are defined as relatively stable beliefs about one’s
work [99]. The most prominent job attitude investigated in the work context is job
satisfaction. Job satisfaction is a positive cognitive and emotional state that results
from the evaluation of one’s job situation [100]. Empirical research has shown that
both personal factors, such as personality characteristics and mood, as well as job
factors, such as task significance and autonomy, influence job satisfaction. In addi-
tion, research across a broad variety of jobs and occupations has demonstrated that
job satisfaction positively predicts work behavior and performance [101]. Thus, it is
likely that health care professionals’ job satisfaction influences their level of engage-
ment in patient safety activities as well as patient safety outcomes.
Some researchers have suggested a more dynamic perspective on job satisfaction
and that not only one, but multiple forms of job satisfaction and job dissatisfaction
exist. They proposed that these different forms of job satisfaction and dissatisfaction
are the result of (a) the difference between what a person wants from work (i.e., their
needs) and what he or she gets out of it (i.e., supply), (b) changes in work-related
expectations over time and due to experience, and (c) proactive coping behaviors to
change one’s work situation and, subsequently, levels of job satisfaction or dissatis-
faction [102]. The resulting dimensions of job satisfaction, which have been validated
in health care settings such as hospitals, are [103]:
1. Stabilized job satisfaction: the employee is generally satisfied with his or her job,
and maintains his or her work-related expectations and resulting job satisfaction.
2. Progressive job satisfaction: even though the employee is generally satisfied with
his or her job, he or she continuously raises the level of work-related expectations
to achieve even higher levels of job satisfaction in the future.
3. Resigned job satisfaction: the employee perceives his or her job satisfaction as decli-
ning and therefore lowers his or her level of work-related expectations to adjust to the
work-related factors that previously resulted in lowered job satisfaction.
4. Stabilized job dissatisfaction: the employee is generally dissatisfied with his or her
job, maintains his or her level of work-related expectations, and does not attempt
to change the dissatisfying job situation.
5. Constructive job dissatisfaction: the employee is generally dissatisfied with his or
her job, maintains his or her level of work-related expectations, but attempts to
change the dissatisfying job situation by engaging in proactive work behaviors.
6. Pseudo job satisfaction: the employee is feeling generally dissatisfied with his or
her job and maintains his or her level of work-related expectations, but denies
that the job situation is dissatisfying (i.e., biased perception of reality).
In addition to job satisfaction, another important work-related attitude is commit-

ment, which can be focused on either the organization (e.g., “I feel emotionally
attached to my organization”) or the profession (e.g., “I feel a sense of belonging to my
profession”). Similar to research on job satisfaction, studies have shown that organi-
zational commitment positively influences employees’ work performance, including
counterproductive work behaviors, across a broad range of jobs and organizations
[104]. Empirical research on professional commitment among nurses has shown that
commitment is positively related to patient safety as well as patients’ perceptions of
the quality of care. Specifically, nurses with high levels of professional commitment
performed better with regard to various indicators of patient safety, including lower
levels of involvement in patient injuries, and had patients who reported higher per-
ceptions of nurse responsiveness and empathy [105].
A well-known psychological theory concerned with the effects of people’s atti-
tudes on behavior is the theory of planned behavior [106], which has frequently been
applied in the health care context [107]. A version of the theory of planned beha-
vior that has been adapted to the context of patient safety is shown in Fig. 3.6. The
Patient safety
attitude
Subjective Patient safety Patient safety

patient safety relevant relevant
norms intentions behavior
Perceived
behavioral
control
Fig. 3.6: Theory of planned behavior; adapted from [106]
theory proposes that three psychological variables influence employees’ intentions to

engage in behavior that are relevant to patient safety which, in turn, influence actual
behaviors. The three psychological variables, which have also been adapted to the
health care context, are:
1. Patient safety attitude: employees’ generally favorable or unfavorable beliefs
about the value and impact of patient safety-related behaviors and activities.
2. Subjective patient safety norms: employees’ perceptions of the typical expectations
in their work environment (e.g., unit, organization) with regard to patient safety.
3. Perceived behavioral control: Employees’ perceptions of how much control or
influence they have over patient safety-relevant behaviors.
As shown in Fig. 3.6, employees intentions to engage in patient safety-related activities

and behaviors should be stronger if (a) they have a favorable attitude toward patient
safety, (b) they perceive that strong and well-established social norms with regard to
high levels of patient safety and quality of care exist in their work environment, and
(c) they feel that they can actually engage in patient safety-relevant behaviors without
being constrained by factors in their work environment (i.e., high levels of perceived
behavioral control). Employees’ intentions should, in turn, positively predict their
safety-related behaviors. It is important to note that employees’ perceived behavioral
control also has a direct effect on their safety behavior. Research has shown that a
moderate positive relationship between employees’ intentions to act in certain ways
and their actual behaviors exists. This relationship is not perfect as other motivatio-
nal factors and external constraints may exist that obstruct the effective translation of
employees’ intentions into behavior. This may be a particularly important limitation
of the theory in the context of patient care, which is carried out in an interpersonal
and team context as well as in complex socio-technical environments.
Empirical research has shown that the theory of planned behavior is a useful
theoretical framework to understand the underlying psychological factors that
contribute to procedural violations that lead to safety incidents and accidents [108].
Specifically, the study demonstrated that employees’ attitudes, work group norms,
and intentions explained approximately 50% of the variance in self-reported safety
violations. A study of fourth-year medical students found that attitudes toward
patient safety were positively related to students’ self-reported safety behaviors [109].
Consistent with the literature on the theory of planned behavior, the study found only
a moderately strong link between patient safety attitudes and associated behaviors.
In particular, the majority of students recognized medical errors and had favorable
attitudes toward patient safety, but actual safety behaviors were less common among
students. For instance, the researchers noted that students generally underreported
medical errors. They also pointed out one possible external reason for the disconnec-
tion between patient safety attitudes and behaviors may be the hierarchical relation-
ships characterized by a steep power distance and traditional authority gradients in
the field of medicine.
Another study examined why physicians’ adherence to hand hygiene, despite
its proven importance for patient safety, remains at a relatively low level in many
hospitals [110]. The researchers collected survey data on hand hygiene perceptions
and beliefs from physicians working in a large university hospital. The results of their
study showed that physicians’ adherence to hand hygiene was only 57% on average,
and that there was substantial variation between different areas of specialization.
Physicians adherence to hand hygiene was predicted by their positive attitude toward
hand hygiene, their awareness of being observed, and their belief that they were
role models for other colleagues (which may be similar constructs to the construct
of subjective patient safety norms in the theory of planned behavior), as well as their
perceived difficulty of accessing hand soap (i.e., perceived behavioral control in the
theory of planned behavior) [110]. In contrast, physicians’ non-adherence to hand
hygiene procedures was predicted by high workload, involvement in patient care acti-
vities with a high risk for cross-transmission, and working in certain areas of patient
care compared to other areas (i.e., surgery, anesthesiology, emergency medicine, and
intensive care). This study provides compelling evidence that physicians’ adherence
to hand hygiene is influenced by their perceptions of their work and personal roles,
their patient safety attitudes and beliefs, as well as external job and professional
influences.
Health care managers may play an important role in shaping their employees’
attitudes toward patient safety. Specifically, empirical research has shown that when
managers openly display a positive attitude toward patient safety, their employees’
attitudes and the general culture of patient safety within the organization (i.e., emplo-
yees’ shared attitudes) are increased [111]. The importance of management support is
also evident from another study with health care professionals working in surgery
teams [112]. While the participants in the study generally reported positive attitudes
toward patient safety, teamwork, and stress management, attitudes toward error
management strategies (including incident reporting and compliance with safety
procedures) were not consistent with a well-functioning safety culture. The study
suggests that while nurses and surgeons were generally more concerned with patient
safety compared to other goals (e.g., cost cutting), they did not feel supported by the
hospital management in this regard.
A few studies in the health care context have also examined the conditions that
influence employees’ patient safety attitudes. For example, a study with more than
2600 physicians investigated how medical error disclosure attitudes depend on the
seriousness of errors [113]. While 98% of participating physicians indicated that they
would disclose serious errors to patients, only 78% of physicians indicated that they
would disclose minor errors to patients. Another study examined patient safety atti-
tudes of operating room staff as an outcome of a communication training program for
medical employees to improve patient safety [114]. The researchers observed positive
changes in attitudes in the majority of medical centers, which indicates that patient
safety attitudes can be improved through planned interventions. Consistent with the
results from the short-term intervention study, a longitudinal study on patient safety
attitudes among medical students found that students’ attitudes improved across a
time span of 5 years of medical training [115].
3.7.2 Emotions
The term “emotion” refers to a subjective feeling or affective state that people experi-
ence and that coincides with a number of physiological changes in different parts and
systems of the body (e.g., the stomach, facial muscles, and blood flow) [116]. Emotions
are usually triggered by certain thoughts (e.g., thinking about a challenging work task
in the next few hours or the symptoms of a particular patient) or by events in the envi-
ronment (e.g., receiving recognition from one’s supervisor or an unpleasant interac-
tion with a patient). A prominent psychological model and classification of emotional
states is the circumplex model [117, 118]. This model, which provides an empirically
derived structure to the vast field of emotions, is shown in Fig. 3.7. In the model, emo-
tions are classified along a circle into four quadrants made up by two orthogonal
axes. The first, horizontal axis is the dimension of unpleasant-pleasant feelings. This
dimension refers to the valence or hedonic tone of emotions. For instance, sadness
is an unpleasant, negative emotional state whereas happiness is a pleasant, positive
emotional state. The second, vertical axis describes the level of psycho-physiological
activation or arousal that accompanies the experience of an emotion. For instance,
boredom as an emotional state involves low activation or arousal whereas excitement
involves high activation or arousal. Numerous basic emotional states, all of which
can be experienced in the work and health care contexts, can be grouped around the
circle.
Activation
Tense Alert
Nervous Excited
Stressed Elated
Upset Happy
Unpleasant Pleasant
Sad Content
Depressed Serene
Bored Relaxed
Fatigued Calm
Deactivation
Fig. 3.7: Circumplex model of emotional states; adapted from [117]
Whereas emotions were a neglected topic in the field of work and organizational
psychology for a long time, more recent work over the past two decades has unco-
vered that affective events, emotional experiences, and the management of emotions
play an important role in the work context [116]. For instance, in the health care work
context, employees’ interactions with supervisors, colleagues, patients, and even the
technical equipment may induce positive or negative emotions that, in turn, are likely
to influence their thoughts, feelings, and work behaviors. A prominent theory that
addresses the role of emotions at work is affective events theory [119, 120], which is
shown in Fig. 3.8.
According to affective events theory, work characteristics influence the types of
work events that employees may experience [119, 120]. Work characteristics include
features of one’s job and work environment such as the complexity and significance
of work tasks, interpersonal demands and resources at work, and the autonomy over
scheduling, work methods, and decisions at work. For instance, working in a health
care context implies that employees will frequently encounter safety-critical work
events such as errors, harmful incidents, or near misses. In addition, work characte-
ristics can have a direct effect on employees’ work attitudes, including their job satis-
faction and organizational commitment as well as their patient safety attitude. For
instance, employees working in a hospital should generally have more positive safety
attitudes than employees in a public library, and employees working in the emer-
gency room may have stronger patient safety attitudes than psychiatrists working in a
private practice. According to the theory, work events may be perceived by employees
as either positive events (“uplifts”) or negative events (“hassles”). Most safety-critical
Health care work Judgment driven

characteristics safety behaviors
Safety-related Experienced Safety

work events emotions attitudes
Individual Affect driven

differences safety behaviors
Fig. 3.8: Affective events theory; adapted from [120]
events such as errors and harmful incidents are clearly negative events; however,
positive events related to patient safety also exist such as recognition received from
one’s supervisor or the relief after a near miss has not resulted in harm to a patient.
Affective events theory predicts that negative work events generally lead to the expe-
rience of negative emotions (e.g., sadness, anger, or anxiety) and that positive work
events generally lead to the experience of positive emotions (e.g., contentment, exci-
tement, or joy).
Individual difference characteristics, such as personality characteristics (e.g.,
extraversion or emotional stability), chronic mood, and emotional intelligence, may
both strengthen or weaken the effects of work events on experienced emotions. They
may also directly influence experienced emotions. For instance, employees with high
levels of emotional stability are generally more likely to experience positive emo-
tions and less likely to experience negative emotions. Chronic mood refers to gene-
ralized feelings that are not linked to a specific thought or event, and their intensity
is generally lower than the intensity of specific emotional states. People often do
not recognize their chronic mood due to the mood’s low intensity, but they usually
notice emotional states such as anger or sadness. Two widely researched types of
chronic mood are positive and negative affectivity (which are positively related but
distinct from extraversion and neuroticism/emotional stability, respectively). People
with high positive affectivity have the general tendency to experience and express
many positive emotions in their lives, such as happiness, confidence, and energy. In
contrast, people with high levels of negative affectivity are more likely to generally
experience and display many negative emotions, such as sadness, anxiety, hostility,
or guilt.
According to affective events theory, employees’ experienced emotions may lead to
two distinct forms of behavioral outcomes, affect driven behaviors and judgment driven
behaviors [119]. Affect driven behaviors include rather impulsive, emotionally-laden
acts, such as starting a fight with a colleague or spontaneously leaving work early
(counterproductive work behavior), helping a colleague or going the extra mile by
putting in extra effort to finish a project (spontaneous citizenship performance). In
the health care context, a negative safety-related event may lead to the emotional
experiences of sadness or guilt in employees which, in turn, may trigger spontaneous
behaviors (i.e., ameliorating actions) that are intended to calm the patient or improve
his or her mood (e.g., by asking his or her family members to enter the room). Alter-
natively, judgment driven behaviors are only indirectly caused by discrete emotional
experiences. Specifically, emotional experiences at work influence employees’ job
attitudes (e.g., their patient safety attitude) which, in turn, affect judgment driven
behaviors. In the health care context, repeated negative events related to patient
safety may have triggered the emotions of anxiety and concern among employees,
and these experiences subsequently improve their patient safety attitudes. These
positive patient safety attitudes, in turn, should result in deliberated behaviors that
will help to reduce future risk of patient safety incidents such as participating in trai-
ning on patient safety.
A recent review of the literature on health care professionals’ emotions, decision
making, and behavior as well as the interrelationships among these factors, con-
firmed that employees’ emotions may influence patient safety outcomes [121]. The
researchers argued that health care professionals’ emotions at work are influenced by
a number of factors including:
– Patient characteristics (e.g., type of medical issue, personal characteristics of
patients)
– Work characteristics (e.g., current workload and time pressure)
– Physical and psychological characteristics of employees (e.g., energy and fatigue)
– Seasonal variables (e.g., increase in cold symptoms leads to more patients and
more negative emotions due to overload)
Consistent with propositions by affective events theory and the psychological litera-
ture on decision making, the researchers suggested that health care professionals’
emotional states may cause affective biases in decision making which, in turn, may
give rise to medical errors and adverse events. Interestingly, the researchers argued
that health care professionals’ clinical reasoning and judgment skills are especially
vulnerable to the experience of positive and negative emotions, because these skills
involve elements that are more intuitive and processes.
3.8 Occupational stress
Occupational stress as well as its various antecedents and consequences constitute

an important field of research within psychology and especially the subfields of
work and organizational, as well as occupational health psychology. Occupational
health psychologists are particularly interested in the use of psychological theories to

understand, predict, and improve the quality of work life by protecting and promoting
the physical health, psychological well-being, and safety of employees [7]. These goals
are relevant to the health care context, as occupational stress may not only negatively
influence employees’ personal safety but also the safety of their patients. Consequently,
numerous empirical studies have examined occupational stress and well-being in the
health care industry. The concept of stress generally does not refer to a state but to
a process in which certain stressors lead to the individual experiences or subjective
states of strain and well-being [122, 123]. Figure 3.9 depicts a general stress process
model. Briefly, the model suggests that stressors (e.g., objective negative events in the
work environment) lead to the experience of acute strain in employees. Acute strain
such as feelings of exhaustion, irritation, headaches, or stomach pain may only last
for a few hours. However, over time, the accumulation of several acute experiences of
strain may give rise to the experience of chronic strain or longer lasting illness.
The negative effects of work stressors on acute strain and, subsequently, chronic
strain may be buffered or alleviated if employees possess high levels of individual or
contextual resources. Individual resources include, for instance, high levels of emoti-
onal stability, emotional intelligence, or a positive patient safety attitude. Contextual
resources are found outside of the individual and include job characteristics (e.g.,
autonomy over decisions), social support (e.g., from supervisors), and organizatio-
nal rewards. Finally, both acute and chronic strain may impact on important work
outcomes, including patient safety. Research in the health care context is generally
supportive of this stress process model. For instance, a study with over 8500 nurses
working in Canadian hospitals examined relationships between work environment
factors, strain, and reports of adverse patient events [124]. The results of the study
showed that the inadequacy of staffing (a work stressor) influenced nurses’ level of
psychological strain, which subsequently influenced patient safety. The components
of the model will be discussed in further detail in the following sections.
Individual
resources (buffers)
Chronic strain
Stressors Acute strain
(illness)
Work outcomes
Contextual
(including patient
resources (buffers)
safety)
Fig. 3.9: General stress process model

3.8.1 Work stressors
Stressors are defined as physical or psychological demands in the work environ-

ment that are perceived as challenging or taxing by most employees and that have
the potential to deplete employees’ resources and lead to negative outcomes [122].
Examples of work stressors are:
– Heat, cold, humidity, noise, and bright lights
– Excessive work demands (e.g., work overload or time pressure)
– Errors, harmful incidents, near misses, and other negative patient safety-related
events
– Ambiguity about work responsibilities and conflict between multiple work
roles
– Work schedule demands (e.g., shift work)
– Interpersonal conflict (e.g., negative interactions with coworkers, supervisors, or
patients) and emotional labor (i.e., regulating emotions to meet work demands;
for instance displaying positive emotions when feeling exhausted)
– Work constraints (e.g., missing or unsuitable work equipment, lack of autonomy)
– Work-to-family or family-to-work conflict (or other work-life role conflicts)
Excessive workload and resulting fatigue of health care professionals may be impor-
tant contributors to patient safety incidents. A study on the predictors of surgical
errors based on interviews in which 38 surgeons from three hospitals identified 146
incidents of surgical adverse events [55]. Fatigue and excessive workload contri-
buted to 33% of the incidents reported. In a study on work stressors and resources
as causes of medical errors, Finnish, American, and British nurses reported that
stressors related to the notion of “demanding practice” frequently led to errors in
operating room teamwork [125]. “Demanding practice” included the fear of errors,
turnover in teams, overtime work, and emotional work stressors. In addition, the
results of the study showed that resources related to the notion of “shared res-
ponsibility ” helped to prevent errors. “Shared responsibility ” involved working in
familiar teams, safety control, and formal documentation of errors. Another study
examined the relationship between nurses’ perceptions of job demands and their
reports of patient safety outcomes [126]. Results from this survey study with 430
registered nurses working in two community hospitals in the United States showed
that nurses’ perceptions of high job demands are associated with lower levels of
patient safety.
A study with 458 nurses from Taiwan investigated the relationship between time
pressure as a work stressor in nursing on the one hand and patient safety (indicated
by the frequency of adverse events) on the other [127]. The researchers also exami-
ned whether emotional strain influenced the effect of time pressure on patient safety.
The results of the study showed that time pressure negatively predicted patient safety
(i.e., low frequency of adverse events), but only among nurses with high levels of
emotional strain. In contrast, the effect of time pressure on patient safety was weaker
among nurses with low emotional strain. The findings suggest that low emotional
strain acts as a buffer of the effect of time pressure on patient safety, whereas high
emotional strain intensifies the negative effects of time pressure on patient safety.
Consistent with these findings on time pressure, a review of research published in the
psychological and human factors literature on interruptions at work has suggested
that interruptions may be a risk for patient safety and task efficiency [128].
Another common work stressor in the health care context is the requirement for
multitasking. In a study with 27 physicians from one hospital, the researchers found
that physicians were, on average, multitasking 21% of their time at work. In addition,
the average time that physicians spent multi-tasking was positively related to both
self-reported work performance as well as self-reported physical and psychological
strain [129]. Thus, multi-tasking appears to be a double-edged sword that increases
performance, but at the cost of increased strain. An explanation for the detrimental
effects of stressors such as multitasking on patient safety is that such stressors place
high demands on cognitive functioning which, in turn, may lead to cognitive errors
that are detrimental to patient care. In a study with 96 registered nurses in 11 hospitals
in Switzerland, the researchers found that task-related stressors were associated with
failures in attention regulation and action exertion, even after controlling for the per-
sonality characteristics of conscientiousness and neuroticism [130]. However, other
research is less conclusive with regard to the effects of work stressors and patient
safety outcomes. In a study with 193 care clinicians from 15 ambulatory health centers
in the United States, the researchers found no significant associations between cli-
nicians’ stress level and incorrect diagnoses of myocardial infarction, breast cancer,
and colorectal cancer [131].
Emotional labor is a work stressor that involves the generation and regula-
tion of emotions at work to fulfill the requirements of one’s job or organization
[132 ]. Emotional labor is typically found in customer service occupations, but has
also important implications in the health care context. For instance, nurses and
physicians may have to show compassion to a patient despite feeling exhausted.
Another example may be that physicians are required to demonstrate authority
when they are asking patients to exercise more or to take their medication regu-
larly. On the other hand, patients often expect health care professionals to show
emotions such as compassion, friendliness, and to suppress negative emotions
such as exhaustion and anger. Researchers have distinguished two basic emotio-
nal labor strategies:
1. Surface acting: this strategy involves faking one’s emotions, that is, pretending to
feel a certain way while in reality feeling a different way. This strategy has more
negative effects on employees’ strain and well-being.
2. Deep acting: this strategy involves changing one’s actual behaviors, for instance
putting oneself into a better mood while on the way to work. This strategy has
less negative effects on employees’ strain and well-being.
Finally, another frequent work stressor is psychological contract breach, or the

perception that one’s organization or its representatives (e.g., supervisors) have
not acted consistently with an unspoken exchange agreement between oneself
and the organization [133]. This implicit agreement involves certain commitments
that the employee has accepted and is carrying out on a daily basis (e.g., ensuring
patient safety) as well as certain expectations regarding what one should receive
from the employer in return (e.g., fair treatment, a secure job, pay raises, training
opportunities). If the employee perceives that the organization has not fulfilled
its promises made in the past, the employee may perceive that the psychologi-
cal contract has been breached, potentially resulting in psychological strain and
lowered well-being, negative job attitudes, as well as counterproductive work
behaviors directed at other people or the organization (e.g., retaliation by sabota-
ging patient care).
3.8.2 Strain
Strain is defined as the reaction or response to stressors [122 ]. Strain constitu-

tes the counterpart of subjective and psychological well-being, which are marked
by feelings of happiness and meaningfulness [134]. Different categories of strain
include:
1. Physical strain: this category includes health problems such as heart disease,
digestive problems, back pain, headaches, and increased blood pressure.
2. Psychological strain: this category includes cognitive and emotional symptoms
such as burnout, depression, anxiety, and sleep problems.
3. Behavioral strain: this category includes behavioral outcomes such as unex-
cused absences, lateness, turnover, alcohol and drug abuse, accidents, sabotage
and violence, and poor decision-making and information processing.
Strain can be either acute or chronic. An example of acute strain is the subjective
experience of fatigue or exhaustion. A review of research on fatigue among anesthe-
siologists highlighted the impact of fatigue on these health care professionals’ cogni-
tive and motor performance [135]. In addition, the authors report that more than 50%
of anesthesiologists indicated that they had made errors in medical decisions due to
fatigue. This research suggests that the consequences of fatigue render this form of
psychological strain a significant risk for patients.
Another study showed that sleep deprivation, a form of psychological strain
that is associated with working long shifts (e.g., 24 hours), is related to the increa-
sed occurrence of medical errors [136]. Specifically, this research found that sleep-
deprived trainees who worked for 24 hours in intensive care units made more serious
medical errors, were more likely to accidentally injure themselves with a needle or
other sharp instrument, and crashed their cars more often on their way to or from
work than trainees who worked only up to 16 hours.
An example of chronic strain is the so-called “burnout syndrome.” Burnout
refers to an extreme and longer-term condition of psychological strain that is the
result of exposure to chronic job stressors that go beyond an individual’s coping
resources [137]. Researchers have proposed three distinct but related components of
burnout [137]:
1. Emotional exhaustion: employees feel emotionally drained from their work.
2. Depersonalization: employees are hardened by their work and may treat patients
with cynicism, like objects.
3. Low personal accomplishment (or reduced self-efficacy): employees believe that
they are not able to deal successfully with task demands and problems.
Empirical studies suggest that the relationship between burnout among nurses
and patient safety appears to be well-established in the psychological and health
care literature [127]. A recent study examined the association between nurses’
level of burnout and patient safety indicators, including perceptions of patient
safety and perceptions of the likelihood of reporting safety-relevant behaviors.
The study found that burnout was related to decreased perceptions of patient
safety and the reporting of errors that did not lead to adverse events, but it was
not associated with perceptions of event-reporting behavior [138]. In summary,
minimizing acute and chronic strains in the workplace is important, because it
can have negative effects on cognitive (e.g., memory, reaction time, and focusing
attention) and attitudinal (e.g., satisfaction and self-efficacy) predictors of work
performance.
3.8.3 Resources
Resources have been defined as anything valued by employees and that may mini-
mize employees’ levels of strain, maximize their well-being, or weaken the delete-
rious effects of stressors on strain. Broadly defined, resources may include objects
(e.g., home, clothes, food), personal characteristics (e.g., self-efficacy), conditions
(e.g., being married or living with someone who provides social support), and ener-
gies (e.g., motivation) [139]. Individual resources for managing stress in the workplace
include:
– Ability to reflect on personal stressors and strains (i.e., self-awareness)
– Ability to manage multiple life roles
– Emotional stability
– Knowledge about stress management
– Stress management skills
Contextual resources include:

– Ergonomic work environment
– Friendly interactions with customers and patients
– Flexible work hours
– Positive organizational culture
– Social support from family, friends, coworkers, and supervisors
Social support is arguably one of the most important and most widely researched
resources for dealing with work stressors, including patient safety-related events
such as errors and harmful incidents. It has been defined as the assistance that an
employee receives through formal or informal relationships with other people, inclu-
ding family members, colleagues, and supervisors [140]. It is generally assumed that
social support directly reduces strain, or acts as a buffer that weakens the negative
effects of stressors on strain (buffer or moderator hypothesis) [141]. In other words,
social support may not only protect employees from high levels of strain, it may also
be particularly effective for employees who face high demands. Psychologists have
distinguished between four types of social support [140]:
1. Instrumental support: form of assistance that involves direct and practical help
offered to another employee.
2. Emotional support: form of assistance that involves an understanding of and
empathetic caring for another employee’s problems.
3. Informational support: form of assistance that involves providing information and
advice that may help another employee solve a problem.
4. Appraisal support: form of assistance that involves providing feedback and opini-
ons to another employee such that this employee’s self-esteem is enhanced.
3.8.4 The transactional stress model
An important theory in occupational stress research is the transactional stress model

[142], which outlines the processes leading from work stressors to the experience of
strain. This model is particularly applicable to the context of health care, in which
employees have to evaluate and react to various stressors, ranging from errors and
harmful incidents over interpersonal stressors to failure of technical equipment.
A simplified version of this model is depicted in Fig. 3.10. The model suggests that
stress is a dynamic process that unfolds over time as people interact with their envi-
ronment. Specifically, the model proposes that people’s responses to environmental
stressors are influenced by individual differences in the appraisal of stressors, that
is, people’s first interpretation and re-interpretation of the stressors and their own
coping resources. Stressors will only lead to the experience of strain when they are
appraised as threats to the person’s well-being in a primary appraisal. A secondary
Stressor Appraisal Strain Coping
Relieving strain
Reappraisal/emotion-focused coping
Problem-focused coping
Fig. 3.10: Transactional stress model
appraisal also takes place in which the person evaluates his or her coping resources
available. Coping describes the various ways in which employees might deal with the
stressors they are facing.
Stress researchers have distinguished three important categories of coping
strategies [142]:
1. Problem-focused coping: this strategy is used to manage or change the stressor
(e.g., health care professionals might attempt to minimize errors).
2. Reappraisal or emotion-focused coping: this strategy is used to weaken the emoti-
onal impact of the stressor by reappraising the problem (e.g., thinking about the
potential positive outcomes of errors such as learning).
3. Relieving strain: this strategy is used to deal with the outcome of the stressor once
it has occurred (e.g., trying to distract oneself from the emotional consequences
of harmful incidents).
3.8.5 The job demands-control model
Another prominent stress model with significant implications for the health care
context is the job demands-control model [143]. The model, which is shown in
Fig. 3.11, consists of two main dimensions, job demands and job control. Job demands
are defined as employees’ workload or the cognitive and emotional requirements of
the job. Job control refers to a combination of having autonomy for decision making,
scheduling, and choosing method in the job as well as having discretion for using
different skills at work. According to the model, strain is the result of a combination of
high job demands and low job control (“high strain jobs”). Generally, nursing is consi-
dered a high strain occupation in the occupational health literature. In contrast, high
levels of both job demands and job control facilitate learning and the development
of positive behaviors at work (“active jobs”). The other two quadrants in the model
involve low demands and high control (“low strain jobs”), and low demands and low
Opportunities for
active learning and
High development of
positive behaviors
Low strain Active

Job control
jobs jobs
Passive High strain

jobs jobs
Low
Risk of physical,
Low Job demands High psychological and
behavioral strain
Fig. 3.11: Job demands-control model; adapted from [143]
control (“passive jobs”). Recent research has suggested adding social support to the
model, and calling the theory the job demands-control-support model [144].
Empirical research in the health care context is generally supportive of the job
demands-control-support model. In a qualitative study with nurses working with
critically ill patients in the areas of anesthesiology, intensive care, and the opera-
ting room, the researchers found that a combination of high job demands, low job
control, and low social support from colleagues results in increased levels of strain
that may have a negative impact on patient safety [145]. The relationships among
stressful job demands, job control, and the frequency of patient safety incidents
have also been investigated in a study carried out in 19 hospitals in Switzerland
[146]. Across 2 work weeks, 23 nurses reported 314 daily stressful events, of which
62 events were related to patient safety. Of these safety-related events, 40.3% were
related to incomplete or incorrect documentation, 21% were medication errors, 9.7%
referred to delays in delivery of patient care, and 9.7% were violent patients. High
job demands and low job control as rated by trained observers were good predictors
of patient safety.
3.8.6 Stress management strategies
How can employees and organizations deal with work stress? Three types of stress
management interventions based on the transactional stress model are [147]:
1. Primary prevention strategies are stressor-directed: their goal is to reduce the
number and intensity of stressors by changing the nature of the work (e.g., by
decreasing work overload and by increasing scheduling autonomy).
3.9 Ethical decision making 63
2. Secondary prevention strategies are response-directed: their goal is to modify

employees’ responses to stressors (e.g., by providing them with opportunities to
participate in stress management training).
3. Tertiary interventions are symptom-directed: their goal is to minimize the nega-
tive consequences of stressors by showing employees how they can cope more
effectively with these consequences (e.g., employee assistance programs).
A primary prevention strategy may be that hospitals reduce unnecessary variability in

patient demands as well as health care services supply, for instance by reducing elective
admissions. Researchers have suggested that adverse events may be the result of stress
among health care staff due to inadequate staffing, an objective stressor in the work envi-
ronment [148]. Inadequate staffing can become a stressor because many hospitals staff
for average as compared to peak patient demands. Thus, in situations when more patients
than average require care, stress among staff increases and may cause adverse events.
3.9 Ethical decision making
Ethical decision making and behavior have been studied in psychology, including
work and organizational psychology, for a long time [149]. It can be assumed that
ethical decision making among health care professionals is an important component
of patient safety. For instance, health care professionals need to follow the codes of
ethics by their organizations and professional organizations, and interact with pati-
ents in honest, respectful, and responsible ways. Disclosing errors, for instance, is
an important aspect of ethical decision making in health care as it enables patients
to make autonomous and informed decisions. In addition, disclosing errors builds a
trust relationship between health care professionals and patients. An organizational
climate of “psychological safety” is important to create a supportive working envi-
ronment in which health care professionals feel free to report errors and make ethical
decisions without fear of being reprimanded [150].
In a study on ethical decision making, nurses in three hospitals were shown
hypothetical scenarios that described inadequate patient care by a colleague [107].
After reading the scenarios, nurses were asked if they would report the colleague
responsible for the situation to their supervisor. The factors outlined by the theory of
planned behavior predicted nurses’ intentions to report the colleague. Specifically, atti-
tude toward the inadequate behavior explained had a strong effect, subjective norms
had a moderate effect, and perceived behavioral control had a small effect on intentions.
3.10 Summary
This first chapter provided an overview of several individual level factors that may
be related to patient safety outcomes in the health care context. The most important
points based on the theoretical and empirical literature reviewed are summarized in
the following.
1. Patient safety performance can be defined as individual employees’ behavior that
contributes to their organization’s goal of maintaining and enhancing patient
safety.
2. Additional forms of work performance, such as task, citizenship, proactive, and
adaptive performance, can contribute to high levels of patient safety.
3. Individual differences, such as cognitive ability, knowledge, skills, and perso-
nality, can distinguish between employees with different levels of patient safety
performance.
4. Rational, intuitive, and ethical forms of decision making of health care professi-
onals and patients are can lead to positive patient safety outcomes, but decisions
may be negatively biased by the way information is presented and processed.
5. Employees’ motivation to show high levels of effort and performance related to
patient safety can be increased by setting safety goals, rewarding safety perfor-
mance, increasing patient safety self-efficacy, raising awareness of the implica-
tions of patient safety, and by creating a work context that facilitates and supports
patient safety.
6. It is important to maintain and enhance positive emotions, employee well-being,
and positive attitudes toward safety as well as to minimize the occurrence of nega-
tive emotions and strain which may be detrimental to patient safety outcomes.
4 Job level influences on patient safety
After the discussion of psychological factors at the individual level as well as their
potential influences on patient safety in the previous chapter, the current chapter is
devoted to job level influences on patient safety. The two main job level influences
that will be described and explained in relation to patient safety are job design factors
and job-related training. Both job design and training are major areas of theoretical
and empirical research within work and organizational psychology [82, 151, 152], and
therefore only key theories and findings as well as their implications for patient safety
will be outlined in this book.
4.1 Job design
Job design refers to the processes of organizing or changing the various features of a job,
while considering requirements of and outcomes for individual employees, the job, and
the organization. Arguably the most prominent psychological theory of job design is
the job characteristics model [153], which is depicted in Fig. 4.1. The job characteristics
model outlines five core dimensions of job characteristics that are proposed to have
motivational effects on employees:
1. Skill variety: the range of skills that are needed to carry out a job (e.g., a nurse
requires both technical as well as interpersonal skills to care for patients).
2. Task identity: the extent to which a job involves completing tasks from the begin-
ning to end (e.g., a physician who oversees the complete treatment of a patient
including follow-ups has high levels of task identity).
3. Task significance: the extent to which a job affects and is important to other
people within or outside the organization (e.g., the work of a surgeon is highly
significant because it involves improving or even saving the lives of other people).
4. Autonomy: the extent to which a job provides employees with discretion and
independence to decide how their work is carried out and scheduled (e.g., a
nursing assistant has relatively low levels of autonomy because his work has to be
performed in a standardized way that does not allow deviations from prescribed
procedures).
5. Feedback: the extent to which employees receive feedback about the outcomes
of their work (e.g., a physician may hear back from a patient she treated after
months with an update on his recovery process and the positive effects of the
treatment).
As shown in Fig. 4.1, the five core job characteristics are hypothesized to influence
three “critical psychological states” of employees. Specifically, skill variety, task iden-
tity, and task significance are proposed to influence employees’ perceptions of the
66 4 Job level influences on patient safety
Core dimensions Psychological states Work outcomes
Skill variety High intrinsic work

Meaningfulness
Task identity motivation
of work
Task significance
High job satisfaction

Responsibility for
Autonomy work outcomes
High safety
performance
Knowledge of work
Feedback results Low absenteeism
and turnover
Fig. 4.1: Job characteristics model; adapted from [153]
meaningfulness of their work; autonomy is proposed to influence employees’ perceived

responsibility over work outcomes; and feedback is supposed to influence employees’
knowledge about the results of their work. These psychological states, in turn, are hypo-
thesized to influence a range of important work outcomes, including favorable emplo-
yee attitudes, work motivation, and work performance. While the job characteristics
model is generally supported by empirical evidence [154], work and organizational
psychologists have derived additional important job characteristics that influence work
outcomes. These include (a) job complexity, information processing demands, problem
solving demands, and specialization (knowledge job characteristics); (b) social support,
interdependence, interaction outside of organization, and feedback from others (social
work characteristics); and (c) ergonomics, physical demands, work conditions, and
equipment use (work context characteristics) [155]. All of these job characteristics are
clearly relevant to the health care context; however, some of them may contribute more
to employees’ patient safety motivation and outcomes than others.
A recent meta-analysis aggregated the findings from 203 studies on the relati-
onships between job characteristics on the one hand and employee burnout, work
engagement, and safety outcomes in the workplace on the other [156]. Results of the
meta-analysis showed the extent to which the job involved work-related risks and
hazards, but also physical demands and job complexity, were associated with emplo-
yee and safety outcomes. Other job design research has investigated the relationship
between working hours and patient safety. One study focused on the prevalence of
extended work shifts and overtime in hospitals and their relationships with patient
safety indicators [157]. Results based on logbooks completed by 393 nurses showed
that nurses usually worked longer than scheduled and that 40% of their shifts excee-
ded 12 hours. The study further showed that the risk of errors increased when nurses
worked shifts that were longer than 12 hours, when nurses worked overtime, and
when they worked for more than 40 hours per week.
Recent research in work and organizational psychology has categorized

different work characteristics into challenge and hindrance stressors [158]. Chal-
lenge stressors refer to those work characteristics and demands that employees
can successfully deal with and therefore have a potentially motivating effect
on employees. Examples of challenge stressors are time pressure and problem
solving demands. In contrast, hindrance stressors refer to work characteristics
and demands that prevent employees from achieving their work goals and thus
lead to frustration. Examples include the existence of red tape in the organiza-
tion and work overload. A recent meta-analysis on the relationships between job
characteristics, safety behaviors, and safety outcomes found that hindrance stres-
sors were negatively related to compliance with safety rules and participation in
safety-related activities [159]. Hindrance stressors were further positively related
to occupational injuries and near misses. The effect of hindrance stressors on
occupational injuries was explained by employees’ engagement in safety behavi-
ors. In contrast, challenge stressors were only weakly related to compliance with
safety rules and participation in safety-related activities as well as occupational
injuries and near misses.
4.2 Training and workplace learning
Training and learning are important research and applied topics in the field of psy-
chology, and in work and organizational psychology in particular [152]. Training of
health care professionals is a possible way to prevent negative patient safety out-
comes such as errors, near misses, and harmful incidents, and to improve positive
patient safety outcomes such as quality of care and positive patient safety attitudes.
Training is generally defined as a systematic and planned activity that leads to the
acquisition of knowledge and skills as well as the change of work-related attitudes.
Training is conducted with the goal of improving performance in the workplace [152,
160]. Learning, a key concept in psychology, is a fundamental basis of employees’
successful participation in training and improved work performance. Learning is
defined as a relatively enduring change in employees’ individual characteristics
(including knowledge, skills, and abilities) as well as behavior, and this change is
shaped by individuals’ training experiences and deliberate practice [47, 152, 160].
The main difference between learning and training is that training is a systematic
and planned activity whereas learning can also be the result of unplanned experien-
ces. The outcomes of employees’ learning processes are multifaceted. Learning can
result in:
– Cognitive changes (e.g., improvements in safety-related knowledge)
– Affective and attitudinal changes (e.g., changes in employees’ patient safety
attitudes)
– Behavioral changes (e.g., development of safety-related skills and strategies)
Training characteristics
(e.g., objectives,
design)
Trainee learning Trainee transfer

(e.g., knowledge behavior (e.g., safety
about patient safety) performance)
Trainee
Work environment
characteristics
(e.g., support,
(e.g., ability,
transfer climate)
motivation)
Fig. 4.2: Conceptual model of training effects
These cognitive, affective/attitudinal, and behavioral changes may lead to improved

work performance (e.g., effective patient safety-related behaviors) on the job, however,
improved work performance due to training is not guaranteed. While training incre-
ases the probability of employee learning, which in turn increases the probability of
improved work performance, it is important to note that training does not determine
learning, and learning does not automatically translate into better work performance.
As shown in Fig. 4.2, the effects of training on learning and performance are influ-
enced by three broad factors:
– Characteristics of the trainee (e.g., ability, motivation to learn)
– Characteristics of the training (e.g., clear objectives, appropriate design, adhe-
rence to learning principles)
– Characteristics of the work environment (e.g., supportive colleagues and super-
visors, a positive transfer climate)
Specifically, Fig. 4.2 suggests that trainee characteristics and training characteristics
influence trainees’ learning outcomes that, in turn, influence trainees’ application of the
training content on the job (i.e., transfer behaviors). Characteristics of the work environ-
ment influence the effect of learning outcomes on transfer, such that the effect is stronger
when the work environment is supportive of trainees’ learning and training activities.
Consistent with the model shown in Fig. 4.2, a literature review of 34 studies on
patient safety training published between the years 2000 and 2009 summarized a broad
range of specific factors that impact the successful implementation of training [161]:
1. Trainee characteristics.
(a) Level of trainee enthusiasm
(b) Competing educational demands of medical students and staff
2. Trainer characteristics.
(a) Expertise in training patient safety and quality of care
(b) Being a role model committed to patient safety
(c) Level of trainer enthusiasm
(d) Time burden to teach the training program
3. Training characteristics.
(a) Combination of didactic and experiential training methods
(b) Adequate time available for training
(c) Scheduling of training
(d) Fit with other training programs
4. Work environment.
(a) Organizational climate for learning and transfer
(b) Hospital leadership and management support
(c) Financial resources for training
A general model of the training process consists of six subsequent steps [152, 160],
which are explained in the following and are shown in Fig. 4.3:
1. Training needs analysis: this step involves a systematic assessment of where and why
training is needed (organizational analysis), who needs to be trained (person analy-
sis), and what needs to be trained (task analysis) (e.g., patient safety is a priority of
the organization, and therefore all nurses need to be trained in error management).
2. Establishment of training objectives: specific goals for the training program are
devised based on the training needs analysis (e.g., the goals of an error management
training may be that nurses are able to detect, report, and deal with medical errors).
Needs
Training
assessment (task,
objectives
person, organization)
Training selection
Gap analysis
and design
Training Training
evaluation delivery
Fig. 4.3: The training process

3. Training design: this step involves the use of psychological learning and training
principles to plan training that facilitates learning, transfer, and performance
(e.g., the hospital hires a consultant to deliver a structured error management
training program).
4. Training delivery: this step involves the flexible adjustment of training and trainer
characteristics to the needs of trainees during the training (e.g., the consult
adapts the pace of the program to the existing knowledge of the trainees).
5. Training evaluation: involves the systematic assessment of trainees’ attitudes and
changes in knowledge, skills, and performance after the training.
6. Gap analysis: involves a comparison between the training evaluation results and
the initial training objectives in order to establish the effectiveness of the training.
4.2.1 Training needs analysis and establishment of training objectives
The purpose of the training needs analysis stage is to derive the objectives of the trai-
ning [160]. For instance, a specific goal of training could be to improve the patient
safety knowledge and attitudes of nurses in a hospital ward. Specific and challenging
training goals fulfill three important purposes:
1. Training goals are helpful for designing the content of the training program (e.g.,
provide trainees with background information on the benefits of patient safety).
2. Training goals can be used to motivate trainees (e.g., more knowledge and better
attitudes will help improve the quality of care and patient safety).
3. Training goals serve as a standard when evaluating the training program (e.g.,
did the patient safety knowledge and attitudes of nurses improve due to the
training?).
The training needs analysis stage can be further broken down into three more
specific steps that help organization gain a better understanding of where and
why training is needed, what kind of training is needed, and who needs to be
trained [160]. First, the organizational analysis involves an examination of the
organization’s goals (e.g., patient safety and quality of care) and needs to find out
in which areas of the organization training is needed, what financial and human
resources the organization has available for training, and the extent to which the
organizational environment is supportive of training (e.g., the front-line supervi-
sors). Second, the task analysis examines the job tasks that trainees perform on a
daily basis and the individual characteristics (e.g., knowledge, skills, and attitudes)
that are necessary to carry out these tasks successfully. Finally, the person analysis
investigates the actual individual characteristics of employees to determine who
needs to participate in training, and in which type of training. Based on the needs
analysis stages, the specific goals of the training should be clearly and explicitly
stated by the organization.
A recent systematic review of 20 research articles on non-technical skills training

designed to improve patient safety reported that the content of patient safety inter-
ventions across studies was quite similar, and focused on five main areas [162]:
– Errors
– Communication
– Teamwork and leadership
– Systems
– Situational awareness
The importance of selecting and designing training programs that are relevant to
employees and the organization is demonstrated by a recent meta-analysis of 110
studies on safety training. Specifically, the meta-analysis showed that the effects of
safety training on the acquisition of safety knowledge as well as trainees’ safety per-
formance depend on the extent to which employees are actually exposed to potenti-
ally hazardous events on the job [163]. Specifically, safety training was more effective
with regard to the acquisition of safety knowledge and safety performance when the
exposure to potentially hazardous events was high. However, when exposure severity
was low, safety training did not affect the outcomes.
4.2.2 Training selection and design
Many different forms of work-related training exist [160], and some may be more appro-
priate for achieving specific training goals than others. In addition, some training may
be more effective in the health care context and for improving employees’ patient safety
knowledge, skills, and attitudes. Examples of different forms of training are [160]:
1. On-the-job training: this form of training involves observation of and learning
from experienced employees and supervisors in a job. On-the-job training can be
conducted in a more or less systematic way (i.e., some training programs involve
explicit goals and feedback sessions whereas other do not).
2. Off-site training: this type of training usually involves employees attending class-
room-type lectures, seminars, and workshops organized by the organization or a
consulting firm.
3. E-learning: trainees work by themselves through computer-based or online training
programs that not only provide them with knowledge but also allow them to check
their knowledge using quizzes as they move through the material at their own pace.
4. Blended learning: trainees participate in both face-to-face training (e.g., on-the-
job or in an external classroom) and complementary e-learning modules.
An increasingly popular form of patient safety training in health care settings is simu-
lation-based training (SBT). SBT involves training tools and methods that are designed
to look similar to the actual work equipment or setting (e.g., an emergency room) and
therefore allow trainees to learn critical skills and abilities needed on the job, to actively
practice the training tasks, and to make errors during the learning process before they
work with patients [164]. In addition, SBT allows trainees to obtain useful feedback in
a simulated yet realistic, safe (for both trainees and patients), and controlled training
environment [160]. Thus, the use of SBT instead of on-the-job training with actual pati-
ents has ethical benefits [165]. A specific example of SBT in health care is called “Anes-
thesia Crisis Resource Management Training,” which uses high-fidelity scenarios that
are based on actual crises (e.g., complications during surgery) to train anesthesia
teams [166]. Other relatively complex and costly forms of SBT include animal models,
human bodies, screen-based simulators (e.g., to train cardiology students), and virtual
reality simulators to train medical procedures, such as surgery [166].
However, SBT can also involve relatively simple and inexpensive tools such as
“manikin simulators” which can be used to train anatomical examinations and first-
aid procedures [166]. Another relatively inexpensive SBT example are “standardized
patients,” that is, trained health care professionals who simulate certain illnesses for
trainees to practice structured examinations [166]. Research on SBT has shown that
both low- and high-fidelity SBTs can improve health care professionals’ knowledge,
skills, and performance. Thus, researchers have recommended the use of well-designed
SBT in the health care context to reduce medical errors and to improve patient safety
and quality of care [166].
Researchers have proposed a number of evidence-based principles and practical
tips for designing SBTs that reduce errors and improve patient safety [166]:
1. Train relevant knowledge, skills, and abilities: practitioners should conduct a tho-
rough training needs analysis (including organization, job, and person analyses)
and develop clear and specific learning goals.
2. Adopt a systems approach: reflect on the factors that influence the success of SBT
before, during, and after the training. It is necessary to prepare employees for
training (e.g., by providing them with information on the training beforehand),
create a pleasant learning environment, and ensure successful transfer.
3. Prepare the organization for SBT: reflect on organizational factors, such as organi-
zational resources for training, the organizational transfer climate, and manage-
ment support for training.
4. Ensure trainee motivation: explain the benefits of SBT to employees and managers.
5. Use learning principles to design SBT: present relevant information, demonstrate
skills to be learned, provide trainees with guided opportunities to practice, and
provide feedback.
6. Develop appropriate performance measures: create simulators and scenarios
that require trainees to show the desired skills and abilities; during the training,
actual behaviors instead of output should be assessed.
7. Set up an appropriate simulation environment: create a pleasant physical and
psychological training environment, provide trainees with learning materials,
and prepare the trainers for training.
8. Prepare the transfer environment: establish a positive organizational transfer

climate, ensuring support from supervisors and management, providing emplo-
yees with opportunities to practice, and reinforcing desired behaviors.
9. Evaluate training effectiveness: compare the initial training goals with training
evaluation criteria such as trainees’ reactions as well as learning, behavioral, and
organizational outcomes.
An interesting and potentially important form of training in the health care context is
provided by error management programs. These programs involve standardized and
structured methods of documenting errors, investigating the causes of errors, learning
from errors, and distributing the lessons learned to others in the workplace. Resear-
chers have argued that health care professionals should learn from the aviation indus-
try with regard to error management programs, even though they acknowledged that
operating rooms are more complex environments than cockpits [6]. However, prob-
lems that exist in both aviation and the health care area and that may lead to errors are
the following: employee failures of compliance, poor interpersonal communication,
flawed decision making, and physiological and psychological shortcomings such as
fatigue, fear, and cognitive overload. Error management programs involve attempts to
learn about the nature and extent of errors as well as their causes and consequences.
They are based on the assumptions that errors are inevitable and therefore need to be
monitored, used for learning, and actively managed to maintain patient safety.
Another interesting and potentially useful training method to improve patient
safety is “storytelling,” which involves oral, written, or video-based presentations of
medical errors and the factors that led to these errors. A review of storytelling best
practices and a survey of hospital safety leaders suggested that storytelling is gene-
rally an effective training method to increase patient safety, but it may also involve
some risk for health care organizations (e.g., taking blame for harm to patients may
have reputational or financial consequences) [167]. In the same article, the resear-
chers presented a video story to hospital personnel, in which the story of the death
of a child due to problems in communication and teamwork was described [167]. The
video was presented in 675 organizations with more than 50 employees. Of these par-
ticipating organizations, more than 90% strongly recommended the use of the video
as a technique to reduce harm to patients, and 85% believed that it either saved lives
or positively affected patients in other ways.
Simulations, error management, and storytelling are still infrequently used in the
health care domain. A review of the research literature that aimed to summarize dif-
ferent teaching methods used to train medical students and health care professionals
in patient safety reported that, out of 41 studies published between the years 2000
and 2009 [161],
– 31 (76%) used didactic lectures
– 16 (39%) used small-group discussions
– 12 (29%) case discussions
– 33 (80%) used experiential learning

– 6 (15%) used web-based modules
The most common training setting was a classroom or another nonclinical setting (23
studies or 56%), followed by ambulatory care settings (18 studies or 44%), and impa-
tient hospital settings (7 studies or 17%). Mixed clinical settings (3 studies, 7%) and
distance learning (2 studies, 5%) were the least common training approaches.
4.2.3 Training delivery
Effective patient safety training should be based on psychological learning theories,

present trainees with relevant content, demonstrate the skills that are required, allow
trainees to practice the skills, and provide them with feedback during practice [160].
First, research on learning in psychology has shown that “whole learning” (i.e., practi-
cing the entire task or skill at once) is more effective when learning well-structured
tasks, whereas “part learning” (i.e., separate practice of several subtasks) is more
effective when learning unstructured tasks. Second, the training content should be
consistent with the training needs identified in the needs analysis and consistent
with the training goals to be relevant to trainees. The concept of “training fidelity”
describes the extent to which a training task is similar to the task that an emplo-
yee has to perform on the job. Generally, the greater the training’s fidelity, the better
employees transfer the training content to the job. Third, training that demonstra-
tes the relevant tasks and subsequently allows trainees to practice, actively explore
the task, and make errors during their learning process are more effective in terms of
trainee learning and transfer. Finally, training that provides employees with feedback
during the learning process are more effective than training programs that do not
provide employees with feedback.
During the delivery of training programs, it is important that trainers pay close
attention to the characteristics of trainees as well as their reactions to training and, if
necessary, adapt the training to better suit trainees needs. Trainee characteristics that
have been shown to predict training success include:
1. Cognitive ability: cognitive ability is the single best predictor of employee perfor-
mance in training programs [168].
2. Learning versus performance goal orientation: employees with a strong lear-
ning goal orientation are motivated to learn, interested in improving their
knowledge, skills, and attitudes, and focus more on the learning process and
less on the results of training [169]. In contrast, employees with a strong per-
formance goal orientation are more concerned about training outcomes, high
performance, and being evaluated favorably which may be detrimental in the
learning process [169].
Organizations could make use of cognitive ability assessments to assign employees to

different types of training. Training for employees with high levels of cognitive ability
could involve more complex training procedures, whereas training for employees
with lower levels of cognitive ability should be designed in a way that allows these
employees to follow the training content (e.g., by providing more structure). In addi-
tion, organizations should attempt to increase the learning goal orientation of trai-
nees. For instance, trainers could set specific and challenging training goals related
to learning and attempting to apply the training content, whereas the performance
outcomes of training should not be emphasized.
It is further important that training programs make use of a number of well-established
learning principles from psychological theories of learning and motivation:
1. Reinforcement theory: this theory proposes that learning is the result of reinfor-
cing behaviors with attractive rewards [73]. For instance, trainers could reward
trainees for showing the desired behavior by praising them in front of their
colleagues.
2. Goal setting theory: this motivation theory suggests that employees should set
specific and difficult training goals for themselves as these lead to high trai-
ning performance. Specific and difficult training goals focus trainees’ attention
and effort on the training tasks, and encourage them develop relevant learning
strategies [67].
3. Social learning theory: this theory suggests that employees can also learn by
observing other employees perform. Behavioral modeling training first presents
trainees with role models who demonstrate the required behaviors, secondly uses
role plays to rehearse the behaviors, thirdly provides employees with feedback on
their performance, and finally asks employees to perform the behaviors on the
job [170].
4. Self-efficacy theory: this theory suggests that trainees with high training self-
efficacy are more likely to succeed in training and when applying the training
content on the job [68]. In order to increase training self-efficacy, trainees should
be provided with as much information about the training as possible, focus on
learning instead of performance outcomes, observe successful role models, and
use learning strategies.
A review of educational strategies used to change physicians’ safety behaviors in

critical care medicine identified five main training delivery techniques [171]:
1. Academic detailing: university-based or non-commercial face-to-face education
delivered by experienced health care professionals, with the goal of aligning
evidence-based best practice with actual medical practice.
2. Audit and feedback: assessment of clinical performance over a specified period
of time and provision of this information to health care professionals to improve
practice.
3. Local opinion leaders: experienced colleagues or supervisors transmit behavioral

norms and model appropriate behaviors in order to improve professional practice.
4. Reminder systems: computerized reminders to improve medical practice.
5. Printed materials: materials to guide self-directed learning among health care
professionals (e.g., books, training guides).
The review concluded that printed materials were ineffective in terms of changing
physicians’ safety behaviors, whereas audit and feedback were not only the most
commonly used techniques but also most effective in terms of changing behavior.
Academic detailing, local opinion leaders, and reminder systems were only some-
what to moderately effective.
4.2.4 Training evaluation and gap analysis
Training evaluation involves a systematic assessment of various training outcomes

that are used to determine whether employees have achieved the goals of the trai-
ning (“gap analysis”) and to make decisions regarding the future training selection
and design [160, 172]. For instance, hospital managers may be interested in trainees’
attitudes and learning outcomes, but also in the evaluation of costs and benefits of a
patient safety training course. Training researchers have distinguished between four
broad categories of training criteria [173, 174]:
1. Reaction criteria: these criteria involve assessments of employees’ perceptions
and beliefs about the training, including measures of employees’ satisfaction
with training and judgments of the utility of training. For instance, survey mea-
sures could be used to assess medical students’ and staff opinions about a patient
safety training program.
2. Learning criteria: these criteria assess what employees have learned in the trai-
ning. Typical assessment methods include oral or written tests of employees’
knowledge and abilities, or examinations that involve trainees demonstrating the
learned skills. For instance, tests could be used to assess health care professio-
nals’ attitudes and knowledge about patient safety both before and after training.
3. Behavioral criteria: these criteria assess how well employees can apply the training
content to their job. For instance, assessment methods include behavioral observa-
tion or coworker and supervisor ratings of employees’ on-the-job performance.
4. Results criteria: these criteria assess the extent to which training has resulted
in improved unit and organizational outcomes, such as reductions of medical
errors and harmful incidents, efficiency of processes, staff absenteeism, as well
as increased patient satisfaction and quality of care.
A systematic review of 20 research articles on non-technical skills training designed

to improve patient safety found that most evaluation measures asked about attitudes
and self-reported knowledge, but actual improvements in knowledge and skills,

behavior changes, and risk reduction on the unit or organizational levels were not fre-
quently captured [162]. One reason for the difficulty of obtaining learning, behavioral,
and results criteria is that they can only be measured some time after employees have
completed the training. With regard to the behavioral and results criteria, an impor-
tant prerequisite for success is that employees can actually apply the knowledge,
skills, and attitudes that they have acquired in training when they return to their job.
This application of training content to the job is called training transfer. Research has
shown that organizations can facilitate transfer of training content by creating a posi-
tive “transfer of training climate” [160]. A positive transfer of training climate invol-
ves a shared attitude among employees and supervisors that training and continuous
learning is important, the provision of opportunities to apply the training content on
the job, access to required resources and positions for training transfer, and coworker
and supervisor support for training transfer.
Another review of the literature on university-based training in patient safety
located 27 studies published between the years 2000 and 2009 that had included trai-
ning evaluation criteria [161]. The results of the review confirmed that reaction and
learning criteria are more commonly used than behavioral and results criteria:
1. Trainee satisfaction was assessed in seven out of ten studies with undergradu-
ate students (70%), and in seven out of 18 studies with postgraduate students
(39%).
2. Trainee attitudes were assessed in eight out of ten studies with undergraduate
students (80%), and in 14 out of 18 studies with postgraduate students (78%).
3. Learning outcomes (knowledge acquisition) was assessed in nine out of ten studies
with undergraduate students (70%), and in 14 out of 18 studies with postgraduate
students (78%).
4. Behavioral change was assessed in three out of ten studies with undergraduate
students (30%), and in two out of 18 studies with postgraduate students (11%).
5. Changes in clinical practice were assessed in one out of ten studies with under-
graduate students (10%), and in 12 out of 18 studies with postgraduate students
(67%).
6. Benefits to patients were assessed in one out of ten studies with undergraduate
students (10%), and in one out of 18 studies with postgraduate students (6%).
4.3 Team training
Research in the health care context has suggested that effective teamwork can greatly
improve patient safety and the quality of care. Accordingly, the availability of team
training in health care has grown over the past decades. While training in team-
relevant knowledge, skills, abilities, and attitudes is not part of the university-based
education of most health care professionals, many health care organizations conduct
team training while on the job. Team training has been shown to be highly effective in
complex and dynamic work environments, including aviation and health care [175].
Researchers have suggested a number of evidence-based principles for designing and
implementing team training that align closely with recommendations on individual
employee training [175, 176]:
1. Before training
a. Ensure relevance of training for the job by identifying critical competencies
(i.e., knowledge, skills, abilities, and attitudes) for teamwork (e.g., mutual
performance monitoring, backup behavior, interpersonal adaptability, and
team orientation) and develop the training goals and content based on this
analysis
b. Align the goals of team training with the organization’s goals
c. Ensure organizational and management support for team training
d. Ensure support by frontline supervisors for team training
e. Prepare trainees and the work environment for team training (e.g., by provi-
ding relevant preparatory information)
f. Ensure the availability of necessary resources such as funding and time
2. During training
a. Use psychological learning principals for training design and delivery
b. Emphasize teamwork (i.e., processes such as communication, coordination,
and collaboration) over task work in training
c. Provide opportunities for guided practice (e.g., high-fidelity simulator, role
plays), and not just passive observation
d. Provide descriptive, timely, and relevant feedback (on behaviors and outcomes)
3. After training
a. Facilitate transfer of training content to the job
b. Evaluate the effectiveness of the team training (not only reactions to
training, but also learning, behaviors, and clinical results)
c. Sustain and reinforce positive teamwork behaviors through on-the-job
coaching and performance evaluation
A number of different approaches to team training exist [152, 175, 176]:

1. Team cross-training: this form of team training involves team members rotating
through different jobs that other employees in the team usually carry out in the
workplace. The goal of cross-training is that each team member gains an under-
standing of the tasks and responsibilities of the other team members. Thus, cross-
training allows team members to develop so-called “shared mental models.”
These models involve a mutual understanding of each other’s tasks, the team’s
goals, and help team members predict the other members’ behaviors. They also
provide team members with an overview of all tasks in the team.
2. Team coordination training: this form of training involves teaching team
members relevant knowledge and skills related to information sharing,
collaboration, conflict management, problem solving, and team decision

making. Team coordination training aims to teach team members how they can
use all of the material and human resources that the team has available in order
to increase team performance, especially in challenging situations. This form
of training is important in the health care context because research in hospi-
tals has shown that the coordination of interdependent team processes that are
necessary to achieve crucial tasks and to maintain patient safety is often not
optimal [177]. Coordination problems may lead to employee stress, the need
to compensate for process losses and, ultimately, errors and threats to patient
safety.
3. Team leadership training: this form of training aims to teach team leaders how
to facilitate and promote crucial team processes such as team communication,
coordination, conflict resolution, and cooperation among team members. It also
addresses various other functions of effective leaders such as visionary commu-
nication, providing constructive feedback, and individualized support.
4. Team self-correction training: this form of training involves training team members
in how to learn from their own errors and those of other team members and to
adapt successfully to change in the work environment.
A popular approach to team training in health care is “crew resource management”

(CRM) training, a specific form of team coordination training. A qualitative review of
26 studies that explicitly mentioned the team training strategy found that 21 studies
(81%) used CRM concepts for team training [175]. CRM training involves providing
team members with knowledge, skills, abilities, and attitudes that are necessary to
respond to highly challenging work situations in an effective, adaptive, and proactive
manner [160, 178]. CRM training has been shown to effectively reduce the risk of errors
and improve safety attitudes in both aviation and health care settings [179, 180]. For
instance, research on CRM training in the operating room, which was guided by avia-
tion pilots in its implementation, led to improvements in error reporting and patient
safety climate, especially among nursing personnel [181].
According to a review of scientific studies on CRM in health care, important pre-
requisites for effective use of CRM in health care include that [178]:
– Health care professionals believe in the effectiveness of CRM training
– Participation in CRM training is reinforced
– CRM training is continuous and not a single event
– The design and delivery of CRM training is based on scientific psychological lear-
ning principals and empirical evidence
– CRM training is evaluated using various outcomes measures
– CRM training involves the use of simulations and other opportunities to practice
– CRM training is consistent with the organization’s goals and safety culture
– CRM training is supplemented by other team-focused training strategies
– Patient involvement
4.4 Summary
This chapter reviewed the literature on job design and training as well as learning in
organizations with a focus on how these job level factors may improve patient safety
in health care. The most important points of this chapter are summarized below.
1. Jobs in the health care context can be designed to increase employees’ satis-
faction, motivation, perceived meaningfulness, and performance that, in turn,
should help maintain and increase patient safety outcomes.
2. Task significance, the awareness of how one’s work benefits patients and other
stakeholders is an important motivational element of job design.
3. Individual and team training can improve patient safety motivation and perfor-
mance if they are well designed (i.e., based on a thorough needs analysis and
clear goals) and delivered (i.e., based on psychological learning principles).
4. Training programs for patient safety should be evaluated using reaction, lear-
ning, and behavioral criteria as well as organizational criteria if possible.
5 Interpersonal and team level influences
on patient safety
Interpersonal processes such as ineffective communication, conflict, and poor

leadership in health care teams constitute some of the most important underlying
factors that cause a large proportion of patient safety incidents and accidents in
health care [182]. Therefore, it is important that individual employees, supervisors,
and organizations aim to improve the quality of these interpersonal processes in
order to maintain patient safety and ensure high quality of care. This chapter reviews
several topics that involve interpersonal processes: patient participation, communi-
cation in health care, teamwork, and leadership.
5.1 Patient participation
The active participation of patients in the health care process can range from patient
participation in medical decisions regarding treatment options over self-medication,
self-monitoring, and patient education to long-term involvement in the management
of chronic diseases. Patients may also proactively and spontaneously participate in
ensuring their own safety by asking their health care provider to prevent infections by
hand washing. Participation of patients is undoubtedly becoming increasingly impor-
tant both from a research as well as an applied perspective [183]. For instance, the
World Health Organization’s (WHO) “World Alliance for Patient Safety” has encou-
raged a greater involvement of patients in health care processes to improve patient
safety [183]. Different labels for patient participation include patient collaboration,
patient involvement, patient engagement, patient partnership, patient empower-
ment, and patient-centered care. From a historical perspective, patient participation
is the counterpart of the traditional model of “paternalistic care,” which assumed
that only experts should diagnose and treat diseases and which views health care
professionals as “guardians” and patients as rather passive beneficiaries of care.
A conceptual model of patient participation is shown in Fig. 5.1. A review of the
literature showed that the acceptance and facilitation of patient participation among
health care professionals is also influenced by a number of health care professional
factors [183, 184]:
– Professionals’ desire to maintain control over the health care process
– Time available for interaction with patients
– Type of medical condition (e.g., health care professionals allow more participa-
tion when dealing with patients with psychosocial problems compared to pati-
ents with somatic problems)
– Knowledge and beliefs regarding patient participation
82 5 Interpersonal and team level influences on patient safety
Factors influencing Factors influencing patients’

healthcare professionals’ ability and motivation to
willingness to accept and participate in the healthcare
facilitate patient participation process
Power and
Situational context
Situational context
and requirements
and requirements
responsibility
sharing
Healthcare
Patient
professional
communication
Effective
Feedback
Fig. 5.1: Conceptual model of patient participation; adapted from [183]
– Training in managing relationships with patients

– Specialty area (e.g., primary care physicians allow more participation of patients)
With regard to specialty area, research with nurses and physicians on health care
professionals’ attitudes toward patient participation showed that both professional
groups generally held positive attitudes toward patient participation in safety inter-
ventions. However, nurses were on average more willing than physicians to support
patient participation [185].
In addition, research in health care settings has identified a number of patient
factors that have been shown to influence patients’ ability and willingness to partici-
pate in the health care process [183, 184]:
– Acceptance of their patient role
– Extent of health-related and medical knowledge
– Health-related and medical self-efficacy
– Type of decision required and stakes of the possible outcome
– Type of patient’s illness, illness severity, and co-morbidities
– Socio-demographic variables such as age (i.e., older patients are generally less
interested in participating), sex (i.e., some studies show that women are more
interested in participating), and education/socioeconomic status (i.e., people
with lower education/socioeconomic status are less interested in participating)
A study with over 2000 patients with chronic diseases examined the predictors of
patients’ participation preferences in medical decision-making [186]. In contrast to
other studies on patients’ participation attitudes, a majority of patients in this study
(69%) indicated that they preferred that their physicians make the medical decisi-
ons for them. Younger, female, and more educated patients were more interested in
an active role than older, male, and less educated patients. In addition, the type of
disease played a role. Whereas patients who suffered from mild hypertension and
depression were more likely to prefer an active role, patients with severe diabetes and
heart disease were less likely to prefer an active role.
Another study investigated relationships between 80 surgical patients’ demo-
graphic characteristics and their willingness to ask health care professionals factual
and challenging about the quality and safety of their treatment [187]. The researchers
used the “Patient Willingness to Ask Safety Questions Survey” (PWASQS), which
includes factual questions such as “when can I return to my normal activities?”,
challenging questions such as “have you washed your hands?”, and questions regar-
ding the influence of health care professionals (e.g., “if you were instructed to by a
doctor would you be willing to ask: ‘have you washed your hands?’”). The results
showed that patients were generally more willing to ask doctors and nurses factual
as compared to challenging questions. A direct comparison of these two professio-
nal groups, however, showed that patients were more likely to ask doctors as com-
pared to nurses’ factual questions and nurses as compared to doctors challenging
questions. Not surprisingly, doctors’ encouragement increased patients’ willingness
to challenge both doctors and nurses. With regard to demographic characteristics,
results were consistent with other studies in that female, employed, and educated
patients were generally more willing to ask questions than male, unemployed, and
less educated patients.
In addition to the health care professional and patient factors listed above, the
model shown in Fig. 5.1 suggests that three interpersonal processes influence the
process of patient participation [183]:
1. Power and responsibility sharing: this process is mainly influenced by health care
professional factors such as those listed above and involves the health care professi-
onal accepting the (partial) loss of expert status and power due to increased patient
participation. In addition, when patients participate in the health care process, the
health care professional has to share his or her responsibility for the health care
process, the outcomes of this process, and patient safety outcomes with the patient.
2. Feedback: this process is mainly influenced by patient factors such as those listed
above and involves the patient providing feedback such as personal and health-
related information as well as opinions to the health care professional.
3. Effective communication: this process is important for both power and responsi-
bility sharing as well as feedback. Effective communication between the health
care professional and the patient facilitates the shift in power and responsibility
over patient care from the health care professional to the patient (e.g., a physician
might explain to a patient why a certain treatment option may be preferable over
another) and helps with providing and receiving effective feedback. Importantly,
effective communication is a two-way process that involves both parties.
A final important element in Fig. 5.1 is the situational context in which the interaction
between health care professionals and patients takes place [184]. A study suggested
that the types of safety-related behaviors that allow patient participation have three
main properties [188]:
1. The type of error that the behavior is trying to prevent (e.g., medication error).
2. The behavior required by the patient (e.g., asking questions).
3. Characteristics of the behavior (e.g., whether the patient is required to interact
with a health care professional or challenge his or her behavior).
The same study also classified different barriers to patient participation into three
broad categories [188]:
1. Intrapersonal barriers (e.g., lack of knowledge).
2. Interpersonal barriers (e.g., lack of communication skills).
3. Cultural barriers (e.g., hierarchical culture).
As suggested above, the type of patient participation may depend on the nature of
the error that patients’ behavior is trying to prevent. Researchers have described a
number of possible roles of patients in the participative prevention of medical errors
that are due to different causes [183]:
1. The cause of medical errors is the health care professional (e.g., wrong deci-
sions due to misinterpretation of data and inadequate assessment of risks,
emotions such as anger and anxiety, fatigue or lack of motivation, insufficient
knowledge and skills, or non-adherence with standard policies, practices, and
procedures).
(a) Patients who are educated in their own care could prevent errors by health
care professionals
(b) Knowledgeable patients can educate health care professionals
2. The cause of medical errors is the medical method applied (e.g., absence of proto-
cols and standardization, complex tasks, technical error, inadequate preparation
and monitoring, delays and interruptions, and inaccurate records).
(a) Educating patients and inviting them to participate can make complex tech-
nical tasks safer
(b) Knowledgeable patients can detect errors in the application of medical
methods
3. Cause of medical errors is equipment (e.g., missing or defect tools, use of wrong
tools, and deficient maintenance).
(a) Knowledgeable patients can detect equipment errors
(b) Patients can join organizational safety boards that can make recommenda-
tions regarding equipment standardization and maintenance
4. Cause of medical errors is measurement (e.g., insufficient data or inadequate error
reporting systems, absence of standards and benchmarking data).
(a) Patient groups can request improvements in error reporting systems and
standardization
5. Cause of medical errors is the work environment (e.g., distractions, poor ergono-
mics, deficient architecture, poor workplace maintenance, and reduced visibility).
(a) Patients can contribute by reducing noise and other distractions in the
health care environment
(b) Patient groups and patients sitting on safety boards can request the design
of more safety-oriented health care environments
6. Cause of medical errors is management (e.g., inadequate staffing, unreasonable
work schedules, budget constraints, and hierarchical organizational culture).
(a) Patient groups could suggest improvements in management
(b) Patient groups could promote quality- and patient-focused management
7. Causes of medical errors are policies (e.g., lack of standards and accountability,
outdated procedures, deficient regulation and legislation, and lack of analysis of
adverse events).
(a) Patient groups can demand the general use of standard operating
procedures, checklists, and adverse event analyses
8. Cause of medical errors is the patient (e.g., provision of incorrect information,
non-adherence with orders, errors, and lack of participation).
(a) Educated and knowledgeable patients are less likely to provide incorrect
information, adhere more to directives, and are less likely to make errors
9. Other causes of medical errors (e.g., lack of constraints, access to patient informa-
tion, automated systems in error-prone areas, and lack of reminders).
(a) Educated and knowledgeable patients can serve as reminders and providers
of important information
(b) Patient groups can promote the use of safety systems in the health care setting
Finally, based on reviews of the literature, researchers have identified a number

of additional recommendations for health care professionals and organizations
related to patient participation that may enhance patient safety and the quality of
case [189]:
– Establish and organizational culture that accepts and promotes patient participation
– Listen to patients and their families
– Incorporate the input of patients and their families into teams, leadership, and
management systems
– Provide patients with exhaustive information about treatment, procedures, and

adverse effects of medication
– Involve patients in patient safety and performance improvement committees
– Disclose medical errors to patients and their families
5.1.1 Interventions to increase patient participation
A number of strategies exist to increase patient participation and, indirectly, improve

patient safety. For instance, researchers have shown that patient-centered interven-
tions can improve patients’ attitudes and behaviors related to patient safety. In a study
with 61 older adults recruited through retirement homes and a family medicine office,
researchers employed the techniques of group education and individual skills trai-
ning [190]. Before and after the training, participants completed the “Seniors Empo-
werment and Advocacy in Patient Safety” (SEAPS) survey. All participants, except
for those with post-high school degrees, benefited significantly from the intervention
with regard to safety attitudes and self-reported safety behaviors in ambulatory care
settings. Another study used an educational video on hand hygiene (“Hand Hygiene
Saves Lives”) to examine whether it changes patients’ patient safety attitudes and
feelings of empowerment [191]. The results showed that, while health care-related
infections were perceived to be common and hand hygiene was generally considered
to be important before watching the video, patients reported being more inclined to
ask their health care professionals to wash their hands after watching the video.
Researchers have offered a practical framework and strategies to increase pati-
ents’ participation in medical decision making [192]. Specifically, the researchers sug-
gested that patients should make decisions in the following three situations:
1. Multiple treatment options exist (e.g., a breast cancer patient can chose between
radical mastectomy and breast conservation surgery).
2. Treatment options offer different clinical or quality of life outcomes or vary in
medical costs.
3. Clinical risks and benefits vary by treatment option.
In addition, the researchers provide examples for situations when the physician
should make a decision instead of the patient [192]:
1. Choosing the best antibiotic for an infection.
2. Deciding when to intubate or extubate.
3. Removing a foreign object or stitching a laceration.
In the same study, the researchers offer a number of strategies to encourage indepen-
dent patient decision making [192]:
1. Health care professionals could ask patients what their worries are and what their
goals are following treatment to clarify patients’ wishes and expectations.
2. Health care professionals should be aware that the way options are presented
(“framed”) might influence patients’ decisions, and that patients’ decisions may
change over time.
3. Health care professionals need to effectively communicate with the patient (e.g.,
using active listening techniques) and they should employ decision aids to help
patients make medical decisions (e.g., a table or other visual aid listing treatment
options as well as their associated risks, benefits, expected outcomes, and costs).
4. Health care professionals should be trained to treat the patient and not the
disease.
How effective are interventions to increase patient participation? A recent study exa-
mined the influence of doctors and nurses encouragement on medical and surgical
patients’ willingness to engage in different safety-related behaviors, including inter-
actional behaviors (i.e., asking factual or challenging questions as well as notifying
doctors or nurses of errors) and non-interactional behaviors (i.e., choosing a hospital
based on the safety record, bringing medicines and a list of allergies to hospital, and
reporting errors to a national reporting system) [193]. Participants were 80 patients
from a teaching hospital in the United Kingdom. The results showed that encourage-
ment by doctors and nurses was only positively related to patients’ willingness to ask
challenging questions, but not to other outcomes. Thus, motivating patients to take a
proactive role in the care process appears to require special encouragement by health
care professionals.
Finally, a systematic review including 21 studies on the feasibility and effectiven-
ess of patient participation found that patients hold generally positive attitudes about
being involved in their own care and safety [194]. However, the researchers found that
patients’ actual behaviors vary more strongly between patients and are not necessa-
rily consistent with patients’ attitudes. Patients’ intention to participate in error pre-
vention was predicted by patients’ self-efficacy, the perceived preventability of errors,
and the perceived instrumentality of behaviors. Overall, the research evidence cumu-
lated in the review suggested that interventions should be sensitively implemented
and designed to promote behavioral change in order for patient participation to be
successful.
5.2 Communication
Effective communication is an essential component of interactions among health care

professionals as well as between health care professionals and patients. Communi-
cation is not only a means to exchange information, but it is also important to make
decisions and to create positive interpersonal relationships [195]. Researchers have
suggested that effective communication is a key ingredient of patient safety and high
quality of care. For instance, studies have shown that the quality of communication
between health care professionals and patients influenced patient health outcomes
such as emotional well-being, blood pressure, blood sugar level, and pain control
[196] as well as patient satisfaction [197].
Communication is an interpersonal activity that involves a meaningful exchange
of information between two or more people [198]. Communication involves the giving
and receiving of information by different persons involved in the exchange. Thus,
communication requires at least one sender, one message, and one recipient. The
sender first has a thought and converts this thought into a message. The message
is then sent to the recipient through a communication channel. Communication
channels may involve speech, writing, or non-verbal behaviors. To understand the
message, the recipient has to decode and internalize it. This basic model of interper-
sonal communication is illustrated in Fig. 5.2.
Communication psychologists have suggested that a message that is sent from a
sender to a receiver can contain four aspects or meanings [198]:
1. Factual information: this part refers to the fact that is stated in the message.
2. Appeal: this part involves asking the recipient to do or change something.
3. Relationship: this part characterizes the nature and quality of the relationship
between the parties involved in the communication.
4. Self-revelation: this part reflects what the sender of the message is communica-
ting about him- or herself.
For instance, if a physician tells a patient in her office, “You should have already seen
me months ago with this issue”, she may come across as rude from the patient’s per-
spective even though she may be indirectly communicating the following meanings
in her message:
1. Factual information: “the medical problem requires urgent treatment.”
2. Appeal: “please invest more into and care more about your health!”
3. Relationship: “I want to help you because I care about you.”
4. Self-revelation: “I am upset because you came to see me very late and now it is
more difficult for me to treat the medical problem.”
Sender Recipient
3. Message is transmitted
through a communication
1. Sender has 3. Recipient

a thought decodes
2. Sender message
encodes 4. Recipient
thought into internalizes
a message
Fig. 5.2: Basic communication model

Based on principles of communication psychology, the following are practical

guidelines for effective communication in interpersonal situations [198]:
1. Attention: as a first step, it is important that both speaker and listener pay atten-
tion to each other. For instance, this involves turning their bodies toward each
other, establishing and maintaining eye contact, nodding, smiling, and making
occasional affirmative sounds.
2. Clarity: messages sent should contain clear information and should be congruent
with regard to verbal and non-verbal communication elements used (e.g., tone,
speed, volume, and facial expression should match what is being said).
3. Feedback: listeners should repeat, paraphrase, and provide feedback to ensure
that they have understood the speaker.
4. Patience: listeners should not interrupt the speaker and wait patiently until the
other speaker is done before you say something.
The above elements of attention, clarity, feedback, and patience are part of the
concept of active listening, which can be effectively applied in health care practice.
Active listening is a communication technique that involves the listener (e.g., the
health care professional) paying close attention to the speaker and patiently feeding
back what they have heard (verbal communication), seen (nonverbal communica-
tion), and understood to the speaker (e.g., the patient). The message can be exactly
repeated (i.e., using the same words as the speaker), paraphrased (i.e., using similar
words and sentence structure as the speaker), or reflected (i.e., using the listener’s
own words and sentence structure) in order to arrive at a shared understanding of the
meaning of the message between the speaker and the listener.
5.2.1 Communication between patients and health care professionals
Early research in the health care context has argued that effective communication
between health care professionals and patients is an essential clinical tool as it posi-
tively influences patient satisfaction, compliance, and health outcomes [199]. Indeed,
interpersonal skills and effective communication are among the characteristics that
patients desire most from their health care providers. In contrast, ineffective communi-
cation between health care professionals and patients still occurs frequently and may
cause threats to patient safety [199]. For instance, it is common that, due to time pres-
sure, health care professionals interrupt patients who are describing their problems
and concerns to them. This may hinder patients to disclose other, possibly more signifi-
cant, problems and concerns to their health care providers. Other problems are that the
technical language and medical jargon used by many health care professionals is not
correctly understood by patients, and that health care professionals often have incor-
rect assumptions about how much and what kind of information patients are interested
in. Given these problems, it is not surprising that many patient complaints about health
care professionals are related to communication and not technical competence [199].
It is important that health care professionals be trained in techniques that

allow for effective communication with patients. Such training involves improving
communication-relevant knowledge and skills, as well as positive attitudes toward
positive communication with patients. Training of techniques for effective com-
munication is not a part of most health care professionals’ formal education. In
fact, medical and nursing education can be quite stressful and even produce rather
negative attitudes toward patients, such as cynicism [199]. A number of recommen-
dations for health care professionals to improve the communication with their pati-
ents are provided in the following:
1. Health care professionals should encourage patients to tell them about their
health-related problems and concerns by using open-ended questions (i.e., ques-
tions that cannot be answered with simply “yes” or “no”) and refrain from inter-
ruptions as well as premature closure and advice.
2. Health care professionals should use the active listening technique and summa-
rize or reflect patients’ problems and concerns to ensure they have understood
the patients.
3. Health care professionals should provide clear explanations and check that the
patient understands what has been said.
Researchers have also provided practical recommendations for patients on how to

communicate with their health care professionals (a “10-step guide for patients”)
[200]:
1. Make a list: it is recommended that patients write down their health-related pro-
blems, concerns, and questions before they visit their health care professionals.
They can then take this list with them to make sure they mention all of their
problems and ask all of their questions.
2. Ask for definitions: it is recommended that patients ask their health care professi-
onals to explain an issue again using simple words and language if they did not
understand something that was explained to them. This is particularly important
when certain words have different meanings in health care and the world outside
of health care. For instance, a “negative test result” may be considered a positive
outcome in health care.
3. Know your goals: patients should ask their health care professionals to define the
health goals set for them. For instance, it is important to know the meaning of the
term “normal” if the goal is to bring back one’s blood pressure into the “normal
range.”
4. Do the talking: it is recommended that patients repeat their health care
professional’s explanations in their own words. This “mirroring” of content
ensures that both patients and health care professionals share a mutual under-
standing of an issue.
5. Picture it: patients could ask their health care professional to sketch a picture to
provide them with a better understanding of an issue. For instance, the picture
could illustrate which parts of the body the health care professional was referring
to and where an operation may be necessary.
6. Slow it down: patients can ask their health care professionals to speak more
slowly so that they do not miss or misunderstand important information.
7. Do not be shy: patients should talk about any concerns that they may have with
their health care professional. This provides health care professionals with addi-
tional information and helps them make better decisions; they might also provide
patients with further information to alleviate patients’ concerns.
8. Consider taking a partner: patients could bring a family member or friend as a
source of support when they visit their health care professional. These people
can also help understand and remember information provided by the health care
professional.
9. Ask for a recap: patients should ask their health care professional to summarize
the most important issues at the end of their appointment in oral or written form.
10. Follow-up: patient should feel free to contact their health care professional if they
feel they have forgotten something important.
5.2.2 Communication among health care professionals
Researchers have investigated the effects of effective communication among health

care professionals on health care outcomes and generally found that effective com-
munication reduces medical errors and increases patient safety [201]. For instance,
a prospective study on patient safety in the operating room showed that problems
in communication and information flow in the team had negative effects on team
performance and patient safety [202]. Another study on communication among
midwives and physicians in the complex environment of the delivery suite found
that inter-professional communication failures influenced preventable errors and
adverse health outcomes [203]. The effectiveness of communication among health
care professionals may also depend on external factors, such as the type or severity
of patients’ illness. A study on physicians’ communication about patients during the
transfer process recorded 36 handover communications at admission in one hospital
[204]. The results showed that in 75% of handovers physicians agreed on the severity
of patients’ illnesses. However, agreement was lower with regard to the most severe
illnesses.
Research further suggests that communication breakdowns or communication
failures in teams are among the most common predictors of threats to patient safety.
An interview study with 38 surgeons from three hospitals suggested that commu-
nication failures in their health care team were the cause of adverse events in 43%
of incidents reported [55]. The only factor that was more common was inexperience
and lack of competence in a surgical task (53% of incidents). In a study on the cha-
racteristics of communication failures in the operating room, researchers recorded
421 communication events, of which 129 (30.6%) were categorized as communication

failures [205]. Communication failure types included
1. Communication occasion (45.7%): poor timing of communication.
2. Communication content (35.7%): information was missing or inaccurate.
3. Communication purpose (24.0%): the issues that gave rise to the communication
were not resolved successfully.
4. Communication audience (20.9%): key individuals were not included.
The researchers further found that 36.4% of communication failures resulted in nega-
tive outcomes, such as inefficiencies, team tension, resource waste, delays, and pro-
cedural error which, in turn, may pose a threat to patient safety [205].
Another study reviewed 444 surgical malpractice claims from four liability insu-
rers and found that in 60 cases, 81 communication failures led to patient harm [206].
Two expert reviewers examined these cases to identify common characteristics and
factors related to communication failures. Communication failures were distributed
relatively evenly between the preoperative (38%), intraoperative (30%), and postope-
rative phases (32%). Factors associated with communication failures in this study
were:
– Status asymmetry (74% of cases)
– Ambiguity about responsibilities (73% of cases)
– Handoff process (43% of cases)
– Transfer of the patient’s location (39% of cases)
– Staff failing to notify the surgeon of critical events
The researchers suggested that intervention to overcome communication failures in

teams should involve implementing warning messages or signs that mandate commu-
nication between the surgeon and operating rooms employees, structured handoffs
and transfer protocols, and standardized use of read-backs (i.e., recipients repeat a
message to ensure it has been properly understood) [206].
Researchers have also examined the factors that predict effective communication
among health care professionals. For instance, a study showed that frequent interrup-
tions of work, inefficiencies, and errors negatively influenced communication in health
care teams [207]. Specifically, the researchers recruited four teams of doctors and mid-
wives who participated in an emergency simulation before and after training. They
then content analyzed team communication and whether clinical and non-clinical
team training improved communication patterns. Two teams received only clinical
training, and the other two teams additionally received teamwork training. Results
showed that all teams generally communicated less after training, and that the teams
that received additional teamwork training used more directed commands after trai-
ning. Directed commands were associated with the acknowledgement and perfor-
mance of specific tasks. The researchers concluded that on-the-job training results in
improvements of communication effectiveness in health care teams. Another study
showed that nurses working in health care units with a weak safety culture were the
least satisfied with their communication with physicians [208]. A third study con-
ducted in a long-term care setting with 325 nurses from 26 organizations examined
nurses’ perceptions of communication between nurses and physicians [209]. From the
nurses’ perspective, the most common communication barriers were feeling rushed
by the physicians and difficulty of reaching physicians, and nurse preparedness for
inter-professional communication. Finally, an intervention study examined whether
medical team training could improve communication among health care professio-
nals working together in the operating room [210]. Surgical team members partici-
pated in a training session which, based on Crew Resource Management principles,
provided didactic instruction, interactive participation, role-play, training films, and
clinical vignettes. Before and two months after the training, participants completed a
survey on their communication. Results showed significant increases in the anesthe-
siologist and surgeon communication scores as a result of the training.
5.2.3 Communicating errors
Communicating errors to other members within the health care teams as well as com-
municating errors to patients is an important professional and ethical requirement, yet
it can be potentially difficult for many health care professionals from an interpersonal
perspective. Research shows that health care professionals find it generally important
but challenging to discuss errors in the work context. For instance, a survey study
with 1033 doctors, nurses, fellows, and residents working in operating rooms and
intensive care units found that only one third of participants felt that medical errors
were handled appropriately at their hospital [211]. Over half of the intensive care staff
reported that they find it difficult to discuss medical errors. Another study with 33
nurses working in intensive care units of four hospitals found that their prioritization
of formal reporting of errors depended on the extent of time pressure experienced, as
well as the presence or absence of actual patient harm [212]. The participating nurses
also reported being strongly conflicted about telling their colleagues and supervising
physicians about errors that these groups had made and they had observed. Speci-
fically, they preferred reporting colleagues’ errors that they had witnesses to their
immediate supervisor rather than to their colleagues. When they had witnessed their
supervisors’ errors, they communicated only indirectly about them with their super-
vising physicians. Importantly, the study also showed that witnessing medical errors
is a severe source of stress for nurses who are conflicted about reporting errors [212].
Researchers have further investigated patients’ reactions to the disclosure of
adverse events in health care settings and their acceptance of different types of apo-
logies offered by their health care professionals. In a study conducted in China, 934
patients and their family members were exposed to two different fictitious disclo-
sure scenarios (minor versus major adverse events) and to one out of six different
apologies conveyed by a physician [213]. The results showed that only immediate and
sincere apologies (including apologetic words and taking responsibility) were accep-
ted by participants. The results further showed that patients, especially younger ones,
were less likely to accept an apology when a major adverse event was disclosed [213].
5.3 Teamwork
Teams are an important way to organize people and structure work in the health
care context, with an increasing focus on multi-disciplinary teams. The National
Quality Forum, a not-for-profit, public service health care organization in the United
States, has established a list of 34 evidence-based “Safe Practices” in health care that
health care professionals should know and use to reduce the risk of harm to pati-
ents. The third of these safety practices refer to teamwork [214]: “Teamwork training
and skill building: Health care organizations must establish a proactive, systematic,
organization-wide approach to developing team-based care through teamwork trai-
ning, skill building, and team-led performance improvement interventions that
reduce preventable harm to patients.” This safety practice provides evidence that
teamwork is considered a crucial requirement for patient safety.
Research on teams and teamwork is a core area within work and organizational
psychology [215, 216]. A team is defined as an interdependent group of individual
employees who are working together toward a shared goal, and employees both within
and outside of the team identify the team as such [215]. Organizational psychologists
have typically used input-process-output models to gain a better understanding of
the predictors and outcomes of teamwork [215]. An input-process-output model of
team functioning is shown in Fig. 5.3. In the model, team input factors (e.g., environ-
mental factors, task-related factors, or the resources a team has available) influence
Team Group processes Team

inputs outputs
Examples:
Examples: Examples:
Leadership
Health care Effectiveness
environment Participation
Quality of care
Organizational Decision making
context Amount of
Communication errors and
Team and incidents
composition coordination
Absenteeism
Team task and turnover
Fig. 5.3: Input-process-output model of team functioning

5.3 Teamwork 95
team process factors (e.g., how the individual members collaborate with each other,
how individual employees take over informal leadership roles, or how teams make
decisions). The team process factors, in turn, influence team outputs (e.g., decision
quality, harmful incidents, effectiveness, or team member satisfaction). As shown
in Fig. 5.3, team outputs may subsequently have a reversed effect and serve as team
input factors. For instance, teams that achieve exceptionally high levels of quality of
care may receive more resources from management than other teams.
Examples of team input factors include:
– Organizational context factors (e.g., organizational rewards such as salary, team
incentives, team training, physical work environment, and technology)
– Team tasks (i.e., the team members’ goal-directed activities)
– Team composition and diversity (i.e., the make-up of the team and differences
among team member in relation to work-relevant attributes)
– Team resources (e.g., financial resources, supervisor support, time to complete
tasks)
Examples of team process factors include:

– Team communication (i.e., transfer of information between team members)
– Team coordination (i.e., the ease with which team members can obtain informa-
tion from each other and understand each other’s tasks and responsibilities)
– Team leadership (i.e., the processes of influence that exist within teams)
– Team cohesiveness (i.e., the degree to which the team members want to remain
part of the team)
Examples of team output factors include:

– Team performance (i.e., team behaviors that contribute to organizational goals,
including safety performance)
– Team productivity (i.e., results of team performance; team output)
– Team creativity and innovativeness (i.e., the generation and implementation of
new and useful ideas in the team)
– Decision quality (e.g., the best choice among several alternative options should
lead to beneficial results)
– Team member well-being (i.e., high levels of team member satisfaction and posi-
tive mood; high levels of perceived meaningfulness of work)
5.3.1 Team composition and diversity
Two particularly important team inputs in the health care context are team composi-
tion and team diversity. Team composition refers to the overall collection of individual
attributes of the team members, including their demographic characteristics but also
their knowledge, skills, abilities, experiences, and personality characteristics. Team
diversity is a complementary construct to team composition as it is defined as the

individual differences between team members on any individual attribute that may
result in one team member’s perception that another team member is different from
him or her [217]. Researchers have further distinguished between [217]:
1. Demographic or social category diversity: differences in observable attributes of
demographic characteristics such as age, gender, and ethnic background.
2. Psychological or functional diversity: differences in underlying psychological
attributes such as professional background, knowledge, skills, abilities, persona-
lity, and attitudes.
Psychological research has generally shown that team diversity constitutes a

double-edged sword with regard to team performance and effectiveness [217]. On the
one hand, team diversity may involve challenges and difficulties due to the fact that
people categorize themselves and others in the team into preferred in-groups (e.g.,
the group of midwifes that one belongs to) and less preferred out-groups (e.g., the
group of physicians). Overall, people prefer to work with and trust others more that
are similar to themselves on demographic or psychological attributes (i.e., in-group
members). Another reason why employees favor working with similar others is that
overcoming differences between people requires resources such as time and effort,
and employees usually aim to conserve these resources. On the other hand, team
diversity may involve opportunities with regard to better problem-solving and gene-
rating ideas because diverse teams have the advantage over homogeneous teams that
their individual members possess a broader and more diverse range of work-relevant
knowledge and skills, complementary abilities, and different ideas and perspectives
that may help solve work problems successfully. In addition, the fact that diverse
groups have to deal with more differences and that conflicts arising from these dif-
ferences may promote a more thorough processing of task-relevant information and
potential risks and benefits. These positive effects of functional diversity are often
intended from the perspective of the organization, for instance in the case of multi-
disciplinary health care teams. Based on these dual effects of team diversity on team
performance, organizational psychologists have developed the social categorization
and information elaboration model of team diversity and team performance, which
is shown in Fig. 5.4 [217]. This model proposes that high levels of team diversity lead
to high levels of social categorization (i.e., “in-group out-group thinking”) as well as
diversity-related negative emotional and evaluative reactions. In addition, high levels
of team diversity lead to high levels of elaboration of task-relevant information and
perspectives. The elaboration of task-relevant information, in turn, positively influen-
ces team outcomes such as safety performance and team decision quality.
The model proposes further that the effect of work team diversity on social
categorization is influenced by a number of important boundary conditions [217]:
1. Cognitive accessibility: this factor refers to the level of difficulty with which team
members can activate the mental representation of the social categorization; for
5.3 Teamwork 97
Cognitive
accessibility Identity
and normative fit threat
of categorization
Affective and
Social
evaluative
categorization
reactions
Elaboration of Safety
task-relevant performance
Team diversity
information and and decision
perspectives quality
Task
requirements,
task motivation,
and task ability
Fig. 5.4: Categorization-elaboration model of team diversity and performance; adapted from [218]
instance, social categories based on sex differences should be more easily activa-
ted than social categories based on professional background.
2. Normative fit of categorization: this factor refers to the extent to which the
social categorization makes intuitive sense to team members; for instance, team
members may easily understand and accept a social categorization based on pro-
fessional background, whereas a social categorization based on height will be
rejected.
3. Comparative fit of categorization: this factor refers to the extent to which the
social categorization leads to subgroups with high within-group similarity and
high between-group differences; for instance, middle-aged employees may not
feel that they are well represented in either a group of “younger employees” or a
group of “older employees.”
The effect of social categorization on affective and evaluative reactions of team

members may be constrained or boosted by the extent to which identity threat is
present [218]. Identity threat refers to a challenge to the value of an employee’s social
identity (e.g., one’s identification with a certain social group, such as the professional
group of nurses). Social categorization is more likely to result in negative affective and
evaluative reactions when one’s social identity is threatened, whereas social catego-
rization is less likely to lead to such negative reactions when identity threat is low.
The effect of team diversity on the elaboration of task-relevant information is also
influenced by a number of boundary conditions [218]:
1. Affective and evaluative reactions: negative emotions and attitudes should disrupt
the link between team diversity and the elaboration of information and perspecti-
ves, whereas positive mood and attitudes should facilitate the elaboration of infor-
mation and perspectives that, in turn, impacts positively on team performance.
2. Task requirements: the effects of team diversity on elaboration of information
should be stronger when (a) tasks require the processing of complex information
and decision making, and (b) when the quality of work is the main performance
indicator of interest (e.g., quality of care), because these tasks require more
elaboration of information and perspectives compared to simple and routine
work tasks.
3. Task ability and task motivation: teams with higher levels of task ability and motiva-
tion should benefit more from high levels of team diversity in terms of elaboration
of information than teams with low levels of task ability and motivation, because
highly capable and motivated teams are better able to capitalize on diversity.
Empirical research in the health care context has hinted at the potential downsides
of team diversity due to social categorization effects. Specifically, a study with sur-
geons and nurses working in the operating rooms of 60 hospitals examined cross-
professional perceptions of communication and collaboration [219]. The results
showed that the percentage of health care professionals rating the quality of col-
laboration and communication as “ high” or “very high” differed both by their own
professional role and whether they were rating a colleague in the same professional
role or in a different role. For instance, surgeons rated other surgeons as “ high” or
“very high” in collaboration and communication 85% of the time, whereas nurses
rated the communication and collaboration with surgeons as “ high” or “very high”
only 48% of the time.
5.3.2 Evidence-based principles for effective team performance
Researchers have suggested that patient safety can be improved by applying

evidence-based principles from team research in work and organizational psycho-
logy, including research on safety in the aviation and manufacturing industries, to the
health care context [220]. These principles, which should enhance the effectiveness
of health care teams as well as outcomes such as patient safety and the quality of care
5.3 Teamwork 99
(especially for health care teams operating in complex, dynamic, and highly stressful
work environments such as emergency medicine) are [220]:
1. Team leadership: research in work and organizational psychology has shown that
effective team leaders contribute importantly to their teams’ performance and help
maintain high levels of performance when the team is facing challenges. Specific
team leader behaviors that facilitate team performance are providing teams with
relevant information, encouraging team members to learn and adapt, structuring
team coordination, facilitating cooperation among team members, and being a
role model for technical and social competencies required for teamwork [220].
2. Individual role clarity and team mental models: team members should have clarity
regarding their own and the other team members’ roles and responsibilities. A
lack of clarity in a role is considered a major stressor in the work context, and
may detract employees from effective functioning within a team. In addition, it is
crucial that team members possess a shared understanding of each other’s roles
and responsibilities (i.e., a team mental model). Team mental models allow each
team member to predict other members’ behaviors, facilitate communication and
cooperation, and provide team members with an overview of the teams tasks and
workflow [220].
3. Feedback: high-quality feedback provided by supervisors and colleagues is an
important requirement for team learning, development, and adaptation. Guided
feedback should be provided both before and after team members’ perform a
task, and there should also be enough time available to discuss the feedback
provided. This process has been called a “pre-brief—performance—debrief cycle”
[220]. During the pre-brief, the team’s goals as well as the team members’ roles
and strategies should be discussed. While the team is performing, team members
should monitor each individual member’s and the team’s performance. During
the debrief session, the team should review each member’s and the team’s per-
formance and discuss which aspects of individual and team performance could
be improved in the future.
4. Team-level beliefs and emotions: team level attitudes, beliefs, and emotions con-
tribute importantly to team performance and effectiveness [220]. For instance,
the concepts of “group potency” and “collective efficacy” describe the team
members’ shared beliefs in the team’s ability to complete a specific task and have
been shown to be positively related to team performance [221]. In addition, team
members’ trust in each other as well as the team’s affective tone can facilitate
the successful functioning of the team [222]. Finally, team level climate, such as
psychological safety climate (i.e., the shared belief that team members are able
to take risks such as talking about errors), can be important contributors to team
learning and performance [150, 223].
5. Team processes: the most important team processes are team member coopera-
tion, communication, and coordination, especially for team working in complex,
ambiguous, and challenging work environments [215]. Research has shown that
high-performance teams cooperate more and use better communication and coor-
dination strategies than less successful teams. In addition, research has shown
that training and team-level interventions, even very short sessions that last only
a few hours, can help improve these teamwork skills and result in improved team
performance [220].
6. Team goals and vision: just as goal setting on the individual level, team goal
setting and a shared vision of the team’s future are important motivational
factors in teams [220]. Team leaders play an important role in communicating
an inspiring vision of the team’s values and purpose, setting clear, specific, and
challenging individual and team goals, and ensuring that team members accept
the goals and vision. Teams with specific and challenging goals and an inspiring
team vision invest more effort and choose better strategies that, in turn, results in
higher levels of team performance.
7. Team error learning and adaptability: high-performance teams have a positive
error management culture that encourages learning from experience and mis-
takes, team self-correction, and adaptability to changes [220]. Adaptability con-
tributes to patient safety, because adaptable teams are in a better position to
adapt existing procedures in challenging and ambiguous situations to fit with the
requirements of clinical practice.
A review of 101 empirical studies conducted in highly dynamic health care settings
(e.g., intensive care and operating rooms) found that ineffective teamwork caused,
and effective teamwork helped prevent, adverse events [224]. Specifically, employees’
perceptions of teamwork and attitudes toward safety-relevant team behaviors were
positively associated with the safety and quality of patient care. Furthermore, percep-
tions of teamwork were positively associated with employees’ well-being that may,
indirectly, contribute to patient safety motivation and behavior. Finally, the observati-
onal studies reviewed indicated that teams’ communication patterns, team coordina-
tion, and leadership support for teamwork predicted team effectiveness and patient
safety performance.
5.4 Leadership
The National Quality Forum, a not-for-profit, public service health care organization
in the United States, dedicated five of their 34 evidence-based “Safe Practices” in
health care to the topic of leadership [214, 225]:
1. Leadership structures and systems (safe practice 1): “Leadership structures and
systems must be established to ensure that there is organization-wide awareness
of patient safety performance gaps, direct accountability of leaders for those
gaps, and adequate investment in performance improvement abilities, and that
actions are taken to ensure safe care of every patient served.”
5.4 Leadership 101
2. Culture measurement, feedback, and intervention (safe practice 2): “Health care
organizations must measure their culture, provide feedback to leadership and
staff, and undertake interventions that will reduce patient safety risk.”
3. Nursing workforce (safe practice 9): “Implement critical components of a well-
designed nursing workforce that mutually reinforce patient safeguards, inclu-
ding the following:
(a) A nurse staffing plan with evidence that it is adequately resourced and
actively managed and that its effectiveness is regularly evaluated with respect
to patient safety
(b) Senior administrative nursing leaders, such as a chief nursing officer, as part
of the hospital senior management team
(c) Governance boards and senior administrative leaders that take accountabi-
lity for reducing patient safety risks related to nurse staffing decisions and
the provision of financial resources for nursing services
(d) Provision of budgetary resources to support nursing staff in the ongoing
acquisition and maintenance of professional knowledge and skills”
4. Direct caregivers (safe practice 10): “Ensure that non-nursing direct care staffing
levels are adequate, that the staff members are competent, and that they have
had adequate orientation, training, and education to perform their assigned
direct care duties.”
5. Pharmacist Leadership Structures and Systems (Safe Practice 18): “Pharmacy
leaders should have an active role on the administrative leadership team that
reflects their authority and accountability for medication systems performance
across the organization.”
These safe practices related to leadership in health care suggest that the importance
of leadership for patient safety outcomes is well established. However, a review of
the literature on leadership in health care reported that most findings were more of
an anecdotal or purely theoretical nature, whereas only 4.4% of articles reviewed
were empirical studies [226]. Of the empirical studies, 41.4% were descriptive studies,
27.9% examined the influence of leadership on subordinates, and only 5% reported
relationships between leadership quality or behavior with patient safety outcomes or
positive changes in health care organizations. The authors of the review concluded
that the evidence for positive effects of leadership patient safety and other health
care outcomes is so far limited. Another review on the outcomes of nursing leadership
similarly suggested that only limited evidence exists for the claim that leadership in
the health care context influences patient safety, and that their review showed that
most studies conducted in health care settings were not properly designed to identify
reliable effects of nursing leadership [227].
Other researchers have been more optimistic, suggesting that the importance
of leadership is receiving increased attention in the health care context and conclu-
ding that leadership has important effects on the quality of care provided, including
patient safety [228]. For instance, a recent study conducted on the Fiji Islands attemp-
ted to examine the impact of senior nursing leaders and managers on patient safety
in hospitals and community health services [229]. Using semi-structured interviews
and thematic analyses, the results of the study suggested that it is important that
organizations empower nursing leaders and managers, that leadership approaches
need to take an increased patient focus into account, and that leaders need to be
aware of the challenging work situation of most frontline nurses to improve patient
safety outcomes. Other researchers have argued that effective leadership is a critical
factor for rapid safety practice adoption, and therefore leaders have the responsibi-
lity to show full engagement in this process [230]. Specifically, the authors suggested
that leaders could help overcome common barriers to the adoption of safety practi-
ces by increasing employees’ awareness of the importance of safety issues, ensuring
accountability, empowering employees and increasing their safety-related abilities,
and motivating employees to act.
Leadership is an important and widely-studied topic within the field of work
and organizational psychology, and the leadership theories and findings develo-
ped in this field could be fruitfully applied in a health care context [231, 232 ]. Lea-
dership can be broadly defined as a process of influencing individual employees
and teams to achieve individual and organizational goals [233]. Consistent with
this definition, a leader is a person who has the ability and motivation to influence
employees and teams to achieve a set of goals that are important for organizational
functioning. For instance, a leader could describe the importance of patient safety
to an employee to motivate him to follow safety procedures closely. A leader may
also explain to employees how the organization’s goal of providing high quality
care aligns with employees’ personal values and interests. Leaders also have the
task of steering team and organizational activities, such a novel patient safety ini-
tiatives. Leadership can occur in a formal role, such as department head or chief
executive officer, or it can be informal and outside of organizational structures.
Consistently, leaders can emerge by formal election or appointment, or they may
informally be accepted and recognized as a leader in a group context. Researchers
have further distinguished “successful” and “effective” leaders. While success-
ful leaders influence employees and change their behavior, effective leaders not
only influence and change employees’ behaviors but also ensure that the beha-
vior change is consistent with the individual’s and organizational goals and that
they, the employees, and the organization are satisfied with and value the behavior
changes.
Organizational psychologists and management researchers have further distin-
guished between the concepts of leadership and management [232, 233]. “Manager”
is a job title that involves certain tasks and responsibilities. For instance, managers
have to deal with the complex and often challenging day-to-day tasks in organiza-
tions such as making realistic and concrete work plans and schedules; ensuring
5.4 Leadership 103
efficiency, order, and consistency; and coordinating employees and monitoring their
performance [232, 233]. Other examples of managerial tasks include:
– Organizing training for employees (e.g., on patient safety)
– Providing employees with information (e.g., on new patient safety regulations)
– Administrative tasks (e.g., reporting errors and processing complaints)
– Recruiting and staffing to ensure high levels of performance and safety
In contrast, “leader” is not a job title and leadership involves inspiring and motivating
employees to work towards shared goals and to cope with changes and challenges
[232, 233]. While some managers may have leadership qualities, not all managers
may be leaders and vice versa. However, research suggests that both leadership and
management are important for effective organizational functioning [234]. Historically,
early research on leadership has focused on the individual characteristics or traits of
extraordinary leaders (approximately 1920s to 1940s). In the 1950s and 1960s, resear-
chers shifted to a focus on leadership behaviors consistent with the dominant beha-
vioral approach in psychology. Subsequently, situational contingency and interactive
theories of leadership were developed. Contemporary leadership theories are mostly
cognitive, affective, and behavioral. The core principles of the most relevant leader-
ship theories for health care are reviewed in the following section, and leadership
interventions in health care settings are discussed at the end of this chapter.
5.4.1 Trait theories of leadership
These early theories argued that leaders were outstanding individuals that could be
differentiated from “ordinary people” based on “traits” or individual differences,
such as cognitive ability and personality characteristics. Thus, these theories implied
that “leaders are born, not made” (or trained). While early empirical research failed
to support this assumption, recent meta-analyses in the work and organizational psy-
chology literature have indeed provided some support for relationships between cog-
nitive ability, Big Five personality characteristics, emotional intelligence on the one
hand and leader emergence and (follower attributions of) leadership behaviors on
the other [235–237]. While these findings have some implications for leader selection
in health care settings, their utility for leader development and training is limited
because traits are stable characteristics that cannot be changed.
5.4.2 Behavioral theories of leadership
Behavioral theories of leadership are more useful with regard to practical applica-
tions in health care as specific leader behaviors can be modified through training or
individualized coaching. Behavioral theories of leadership suggest that effective

leaders can be distinguished from ineffective leaders based on the behaviors they
show in the work context. Thus, according to these theories, “leaders can be made”
(or trained). The most important work in this area focused on two behavioral dimen-
sions [238]:
1. Initiating structure: the extent to which a leader is task-oriented and clearly
defines, structures, and organizes work (including employees’ goals, tasks, roles,
and cooperative relationships) to accomplish relevant organizational goals.
2. Consideration: the extent to which a leader is employee-oriented and has positive
and professional working relationships with employees that are characterized by
high levels of empathy, friendliness, trust, respect, fairness, and support.
A systematic review of research on effective leadership in critical care teams has

provided evidence for the effectiveness of these two dimensions of leader beha-
vior [239]. Specifically, the review showed that health care leaders have significant
effects on team performance and patient safety, and that these effects could be exp-
lained by two critical mechanisms: (a) leaders supported teams to complete their
tasks collaboratively (i.e., initiating structure), and (b) leaders provided individual
support, feedback, development, and encouragement to individual team members
(i.e., consideration). However, health care organizations are complex systems,
and researchers have identified additional critical leadership behaviors in these
contexts that cannot be easily grouped into initiating structure and consideration
behaviors [240]. Specifically, these researchers proposed eight key leadership beha-
viors that are relevant in health care organizations that are considered complex and
dynamic systems:
– Relationship building
– Loose coupling
– Complicating
– Diversifying
– Sense making
– Learning
– Improvising
– Thinking about the future
In addition, the researchers proposed eight complementary leadership behaviors that

are relevant in health care organizations that are considered professional bureaucra-
cies [240]:
– Role defining
– Tight structuring
– Simplifying
– Socializing
– Decision making
5.4 Leadership 105
– Knowing
– Controlling
– Planning based on forecasting
5.4.3 Contingency theories of leadership
Contingency (or situational) theories of leadership expanded the propositions of trait

and behavioral theories by additionally considering the work context and specific
work situation in which leaders should be more or less effective [241]. These theories
argued that the outcomes of leadership are dependent on whether the leader’s beha-
vior has a good fit with factors of the work environment including:
1. Task characteristics: are the tasks to be accomplished by employees simple and
routine or are they complex and challenging?
2. Employee characteristics: are the employees easy to get along with or do they
resist the leader’s efforts and have negative attitudes toward him or her?
3. Situation characteristics: How much influence and control does the leader have
over the employees?
In terms of practical implications for the health care context and patient safety, the
contingency theories of leadership suggest that health care leaders should adapt
their leadership behaviors to the specific situational requirements. For instance, a
more goal- and task-oriented leadership style may be important to prevent errors and
harmful incidents, whereas employees might appreciate a more considerate leader-
ship style in times of crisis, such as in situations after an error or a harmful incident
has occurred.
5.4.4 Leader-member exchange theory
The theory of leader-member exchange argues that leaders have individualized,

“one-on-one” relationships with each of their employees, which means that they may
interact differently with each employee [242]. Due to resource constraints (e.g., time
and energy), leaders cannot have high-quality relationships with each employee,
and therefore, focus most of their time and energy at work on a selected group of
employees that enjoy a high-quality relationship with the leader (in-group). In-group
employees get more attention, are more trusted, and enjoy more autonomy and work-
related opportunities than other employees who belong to the out-group. Out-group
employees have a lower-quality relationship with the leader and the leader uses
more formal power to influence them instead of providing them with interesting and
challenging work-related opportunities. Importantly, employees’ roles may change
over time) to remain in a high-quality leader-member exchange relationship, both
leaders and employees have to invest time and energy resources into the exchange
relationship.
Research has shown that high leader-member exchange quality is associated
with high levels of safety communication and safety commitment as well as low rates
of accidents [243]. Specifically, leader-member exchange quality positively predicted
safety communication that, in turn, positively predicted safety commitment. Safety
commitment subsequently negatively predicted accidents. Another study examined
the joint effects of registered nurses’ trust in their leader (a component of high quality
leader-member exchange) and safety organizing on medication errors reported to the
hospital incident reporting system [244]. Participants were 1033 registered nurses and
78 nurse managers from the emergency, internal medicine, intensive care, and surgery
nursing units in ten acute-care hospitals in the United States. The results showed that
the positive effect of safety organizing on medication errors reported 6 months after
the survey were strengthened when high levels of trust in leadership were present. A
third study also confirmed the important role of followers in the leadership process.
Specifically, the study with 3447 employees from 283 health care teams examined
relationships between team members’ clarity of leadership in their teams, team pro-
cesses, and innovation [245]. The results showed that leadership clarity was positively
related to clear team goals, active team participation, commitment to excellence, and
support for innovation. These team processes, in turn, were positively related to team
innovation.
5.4.5 Participative leadership
Participative leadership is a form of leadership that involves the leader including his
or her employees (i.e., the team) in the selection of goals and tasks, and the develop-
ment of strategies for accomplish these goals and tasks [246]. The leader facilitates
processes and makes the final decisions. Participative leadership is generally con-
sidered a useful approach to leadership in the health care context [246]. To ensure
successful participative leadership, the leader has to recognize relevant work situ-
ations in which employee participation is appropriate and useful. This depends, for
instance, on the importance of the decisions or tasks (i.e., what happens if participa-
tive decision making may lead to negative organizational outcomes?), as well as the
available and relevant knowledge, skills, and abilities in the team. Participative lea-
dership and decision making in the team is futile if the team members do not possess
the necessary requirements for task and goal selection as well as decision making. In
addition, the leader should anticipate problems that may arise when, for instance,
his or her employees are not interested in participation in decision processes or when
they do accept the final decision by the leader. Once the leader has decided to use the
participative leadership approach, it is his or her role to facilitate employees’ partici-
pation, for instance by explaining to them that no final decision has yet been made
5.4 Leadership 107
and that they should feel free to share all of their ideas, expectations, and concerns.
The leader should take a moderator role in this process by writing down employees’
suggestions in an objective and generally appreciate manner, independent of the
content of suggestions and opinions. In addition, the leader could attempt to synthe-
size and integrate different viewpoints and suggestions made by employees.
5.4.6 Transactional and transformational leadership
Transactional and transformational leadership are two complementary leadership

styles that have received a lot of empirical support in the work and organizational
psychology literature [231, 247]. Transactional leaders establish exchange relation-
ships with their employees by guiding and motivating them to achieve goals as well
as rewarding them for successful goal accomplishment [247]. Specific transactional
leader behaviors include [247]:
1. Contingent reward: the leader clarifies goals and expectations, promises rewards
for good performance, and recognizes and rewards employees when goals are
met.
2. Management by exception (active): the leader is concerned about employees
deviating from set standards and expectations, and intervenes proactively when
goal accomplishment is threatened.
3. Management by exception (passive): the leader is concerned about employees
deviating from standards and expectations, but intervenes only once standards
and expectations have not been met.
4. Laissez-faire: the leader is frequently absent and avoids making decisions and
taking responsibility.
Transformational leaders motivate their employees to achieve above and beyond

expectations by appealing to their higher-order needs, interests, and values and by
aligning these needs, interests, and values with organizational goals [247]. Transfor-
mational leaders inspire their employees by acting as a positive role model, commu-
nicating an attractive vision, stimulating creativity, and developing their employees
consistent with each individual’s needs and interests [247]. Dimensions of transfor-
mational leadership behavior include [247]:
1. Idealized influence: the leader acts as a positive and optimistic role model, instills
pride in employees for being a part of the organization, provides a sense of
purpose, and gains employees respect and trust.
2. Inspirational motivation: the leader communicates a clear, inspiring, and attractive
set of goals (vision) for the future along with high performance expectations, expla-
nations, as well as the assurance that employees can meet these expectations.
3. Intellectual stimulation: the leader encourages employees to think in non-
traditional and creative ways about work problems and questions assumptions.
4. Individualized consideration: the leader treats each employee as an individual

and invests time and effort to mentor each employee according to their unique
interests and values.
According to the “full range of leadership model” [247] laissez-faire leadership is not
effective, transactional leadership is effective in motivating followers, and transfor-
mational leadership is highly effective in terms of motivating followers to perform
above and beyond expectations, especially in times of crisis and change. In the
context of changes that influence modern health care systems, researchers have
argued that transformational leadership may be important in the health care context
to empower nurses to take a more holistic perspective and focus on patient-centered
care [248]. In addition, transformational leadership is thought to positively influence
nurses’ job satisfaction and negatively influence turnover [249]. These effects, in turn,
are believed to have a trickle-down effect on patient satisfaction. Other research in
the health care context has suggested that transformational leaders are important to
enhance employees’ perceptions of leader effectiveness and trust in the organization
as well as to facilitate teamwork [250, 251].
Transformational leadership behaviors may be enacted with a particular focus
on workplace health and safety. Research has shown that safety-specific transforma-
tional leadership negatively predicts occupational injuries among restaurant emplo-
yees [252]. The effects of safety-specific transformational leadership on occupational
injuries were explained by the leaders creating an organizational safety climate,
raising safety consciousness among employees, and capitalizing on safety-related
events. Another study proposed that an important mechanism of the effect of trans-
formational leadership behaviors on patient safety is the level of stress and well-
being among employees. Specifically, transformational leadership is thought to
influence employees stress and well-being which, in turn, affect quality of care and
patient safety-related behaviors [228]. Overall, safety-specific transformational lea-
dership appears to be a promising approach in health care. In addition, transactional
leadership may be important to ensure employees’ accountability [228].
5.4.7 Destructive, ethical, and authentic leadership
In recent years, work and organizational psychologists have become more and more
interested in counterproductive and (im)moral leadership behaviors. Destructive lea-
dership refers to leader behaviors that undermine or sabotage (a) the organization’s
goals and effectiveness or (b) employees’ motivation, well-being, and performance
[253]. Destructive leaders may show tyrannical behaviors toward other people in the
organization (e.g., their employees or patients), they may sabotage their employees’
and the organization’s performance, or they may be overly lenient with their emplo-
yees thus also violating organizational norms and expectations. In the health care
context, for instance, destructive leaders may ignore or even violate patient safety
5.4 Leadership 109
procedures and regulations, and they may sabotage organizational rules by not
reporting errors and harmful incidents. In contrast, ethical leaders are concerned
with and act in accordance with moral and ethical principles and would not use
their power to influence employees in unethical, self-serving ways [254]. Finally,
authentic leaders know who they are and what they value, and they act genuinely,
ethically, and consistent with their core values and beliefs [255]. It is likely that the
latter, positive forms of leadership behavior benefit patient safety and employees in
health care.
5.4.8 Leadership interventions in health care
A number of studies have conducted and evaluated leadership interventions in the

health care context with the aim of improving patient safety. First, research on the
“Patient Safety Dialogue,” a leadership-based patient safety intervention, showed
that leadership behaviors were effective with regard to improving indicators of an
organizational patient safety culture [256]. The “Patient Safety Dialogue” involves
conversations between health care leaders and employees who have safety-critical
tasks and responsibilities. The intervention aims to help create a strong organizati-
onal patient safety culture through educating leaders about patient safety and moti-
vating them to influence their teams’ safety attitudes and behaviors. The result of
interventions carried out over 5 years in 50 medical and psychiatric departments of
three hospitals in Sweden showed that between half and 70% of departments had an
improved patient safety culture for hospital-acquired infections and general patient
safety both 18 and 36 months after a baseline assessment. However, one third of
departments showed no improvement over the study period.
Another leadership-based intervention study with 36 leaders and 381 employees
focused on leaders’ monitoring and rewarding of employees’ safety behaviors [257].
As part of the intervention, leaders’ supervisors (i.e., section managers) communi-
cated the importance of safety on a weekly basis to the leaders, and the researchers
provided weekly feedback to leaders on their safety-related interactions with emplo-
yees. The results showed that leaders’ safety practices increased over time, and that
safety became a higher priority than other work goals. In addition, employees’ safety
climate perceptions increased and the rate of accidents decreased. Finally, in a third
leadership-based intervention study, senior hospital executives each adopted an
intensive care unit as part of a patient safety program and motivated employees with
regard to patient safety [258]. The study showed that the “senior executive adopt-
a-work unit program” helped identify and eliminate threats to patient safety and
created a strong patient safety culture. According to the researchers, important
mechanisms of the program’s success were regular meetings between the senior
executive and the employees of each unit, the active role of the senior executives
in facilitating learning and trust, employees’ willingness to discuss safety issues
in their teams, and the speed and effectiveness of addressing potential threats to
patient safety. The program as a whole involved eight steps that were carried out over
a period of 6 months:
– Conducting a safety culture survey
– Educating employees on the evidence-base of patient safety
– Identifying employees’ patient safety concerns using an employee survey
– Implementing the senior executive adopt-a-work unit program
– Implement patient safety-related improvements
– Documenting results
– Disseminating results
– Conducting a follow-up employee survey
5.5 Summary
This chapter reviewed interpersonal and team influences on patient safety. The most
important conclusions from this chapter are summarized in the following.
1. Patient participation is an emerging paradigm in health care that can contribute
to improvements in patient safety.
2. Different factors related to patient characteristics (e.g., previous knowledge and
self-efficacy), health care professional characteristics (e.g., willingness to accept
and facilitate patient participation), situational characteristics (e.g., type of
illness, characteristics of errors), and interpersonal process (e.g., communication
and feedback) that may influence the success of patient participation.
3. Effective communication among health care professionals and between health
care professionals and patients is a crucial element of interventions to maintain
and enhance patient safety as well as when errors have to be communicated.
4. Effective teamwork processes, such as communication and cooperation are
important, especially in multidisciplinary health care teams.
5. Team diversity has potential benefits and disadvantages. Employees and health
care leaders should assist their teams in terms of maximizing the benefits arising
from different perspectives and enhance the elaboration of information. At the
same time, the negative outcomes of social categorization should be minimized.
6. Health care leaders can exert a significant influence on their employees’ patient
safety attitudes, motivation, and performance, and thus, impact objective patient
safety outcomes.
7. The most promising approach to leadership appears to be safety-specific trans-
formational leadership, which includes acting as a role model for safety issues,
developing and communicating an inspiring vision for patient safety, and deve-
loping the patient safety performance of both individuals and teams.
6 Organizational level influences on patient safety
This chapter examines organizational level influences on patient safety, with a

particular focus on organizational culture and climate for patient safety. In general,
organizations are social groups that bring together a number of individuals who
work toward a common purpose [7]. Accordingly, health care organizations are social
units comprised of individual employees who aim to achieve goals, such as maintai-
ning and improving public health and patient safety, as well as profits and securing
employment of their workforces. The focus on higher-order factors at the organizatio-
nal level that may influence patient safety is important, because research in work and
organizational psychology suggests that objective patient safety outcomes such as
medical errors and harmful incidents may be the result of organization-wide shared
attitudes, values, and beliefs. In addition, organizational factors may interact with
lower-level factors such as individual (e.g., decision making biases) and team charac-
teristics (e.g., leadership behavior).
A focus on organizational level factors that influence patient safety is consistent
with an emerging systems approach suggested by most national and international
health care institutions. For a long time, a person-centered approach to the detec-
tion, analysis, and prevention of medical errors, in which the individual emplo-
yee is solely responsible for the occurrence of errors, has dominated research and
practice on patient safety [259]. In contrast, the broader systems approach suggests
that, in addition to factors at the individual, job, and team levels, organizational
factors can contribute to individual behaviors relevant to patient safety and patient
safety outcomes such as errors, near misses, and harmful incidents. A systems
approach also suggests that organizational structures, policies, procedures, and
practices could be designed in a way that prevents individual employees from
engaging in safety threatening behaviors and from making errors. For instance, a
systems approach argues that higher-order factors, such as patient safety culture
and climate, influence individual employees’ patient safety-relevant attitudes and
behaviors.
6.1 Organizational culture and climate
Research on organizational culture and climate has a long tradition in work and
organizational psychology, organizational sociology and anthropology, as well as
business literatures, and continues to flourish to this day [260, 261]. Generally,
culture refers to a broader system in which people have shared perceptions of and
interpretation of things, events, and processes. Organizational culture is defined
112 6 Organizational level influences on patient safety
Goals
technology
Overt aspects structure
policies and procedures
Beliefs, assumptions
Covert aspects perceptions, attitudes
feelings, values
informal interactions
groups norms
Fig. 6.1: Model of organizational culture
as the implicit and shared beliefs, assumptions, attitudes, feelings, values, and
norms that exist in an organization [260]. The concept of organizational culture can
be illustrated using the metaphor of an iceberg (Fig. 6.1). While the organization’s
goals, technology, structure, policies, and procedures are overt aspects of the
organization, visible to both in- and outsiders, organizational culture refers to the
covert aspects that are “under the surface” and are thus not easily discovered by
outsiders.
Organizational climate refers to the shared perceptions among employees
regarding their work environment, in particular regarding the organization’s formal
policies, the procedures that transfer these policies into behavioral guidelines, and
the resulting everyday practices that members of the organization engage in [260].
In other words, organizational climate is a construct that refers to “the way we do
things around here.” Researchers have argued that different organizational clima-
tes may exist within a single organization that describe employees’ shared percep-
tions regarding topics such as sustainability, innovation, customer service, work-life
balance, safety, and error management. In contrast to organizational culture, which
has its roots in the field of organizational anthropology, organizational climate has
been mostly investigated in the work and organizational psychology literature.
Organizational culture and climate are distinct but overlapping and related con-
structs. Specifically, organizational culture involves the organizational members’
shared perceptions and interpretations of the policies, practices, and procedures that
make up an organization’s climate [261]. In addition, researchers have distinguished
between the concept of “organizational climate” and the concepts of “perceived” or
“psychological climate” [262, 263]. Perceived or psychological climate refers to indivi-
dual employees’ perceptions of the organization’s climate, whereas shared employee
perceptions that can be aggregated to the organizational level (after sufficient agree-
ment among ratings has been established) constitute organizational climate. Finally,
another important construct related to organizational climate is “climate strength,”
or the extent to which individual employees agree in their shared perceptions and
ratings of the organizational climate [262, 263].
6.2 Patient safety culture and climate
Based on the definitions provided in the previous section, patient safety culture
can be defined as the shared and implicit beliefs, assumptions, attitudes, feelings,
values, and norms regarding patient safety that exist in an organization. Patient
safety climate can be defined as employees shared perceptions regarding patient
safety-relevant policies, procedures, and practices that exist in their organization.
While these are important conceptual differences, most research in the health care
literature has not distinguished between the concepts of patient safety culture and
climate but used them interchangeably to describe employees’ perceptions of their
organization’s approach to patient safety (which may include implicit attitudes,
values, and beliefs held by employees as well as explicit policies, practices, and
procedures). In addition, most studies on patient safety climate have not distin-
guished between individually perceived or psychological climate and shared,
organizational-level climate. A potential reason for the conceptual and methodolo-
gical limitations is that the ideas of patient safety culture and climate are relatively
new to health care research and practice. In addition, establishing and maintaining
a safety culture or a safety climate are not easy tasks, and it may take months or
years to see their effects. Indeed, human factors researchers reported that a safety
climate was 12 times more evident in naval aviator squadrons than in hospitals
[264]. However, over the past decade organizational psychologists and human
factor specialists have increasingly researched and established patient safety cultu-
res and climates in hospitals. Consistent with the existing health care and patient
safety literatures, the terms culture and climate will be used interchangeably in the
following sections. However, it remains an important task for future researchers to
disentangle these constructs and apply them separately in the health care context
consistent with recommendations in the contemporary work and organizational
psychology literature [260].
It is important to note that differences in safety culture and climate do not only
exist at the organizational level, but may also exist in smaller social units located at
lower levels in the organization, such as departments, teams, and work groups. For
instance, a study with 534 employees from 53 teams showed that employees within
teams agreed upon the extent to which their supervisors engaged in safety practices
that positively influenced employees’ shared perceptions of the team’s safety climate
[265]. The study further showed that team safety climate negatively influenced acci-
dents during a period of 5 months after the safety climate assessment. These results
held up even after statistically controlling for a number of employee- and team-level
risk factors for accidents. Another team-level study on safety climate showed that the
extent to which organizational policies allowed discretionary actions by supervisors
positively influenced teams’ safety climate which, in turn, facilitates employees’ safe
behavior [266].
6.2.1 Dimensions of safety culture and climate
There is a general agreement among health care researchers that patient safety culture
and climate in health care settings are multidimensional concepts. A qualitative study
in hospitals identified seven important aspects of a positive patient safety culture/
climate [267]:
1. Leadership: leaders provide a vision, ensure employee development, and secure
resources for patient safety.
2. Teamwork: working relationships are open, respectful, and based on collegiality
and cooperation to maintain patient safety.
3. Evidence-based: patient care is based on scientific evidence and standardization.
4. Communication: employees have the right and the responsibility to speak up on
behalf of patients to secure patient safety.
5. Learning: employees and the organization learn from errors and value and seek
out learning opportunities.
6. Just: both latent and active factors are taken into account when analyzing and
evaluating errors, and employees and supervisors are held accountable for their
safety-related behaviors.
7. Patient-centered: the health care process is centered on the patient, and patients
are active participants in their own care.
Another review of different patient safety culture and climate measures identified the
following themes [268]:
1. Management/supervision: this dimension includes questions about management
and organizational commitment to patient safety, adequacy of training and
supervision, organizational responses to safety-related issues, and non-punitive
response to error.
2. Safety system: this dimension includes questions about detection infrastructure,
handoffs and transitions and coordination of care, patient safety planning, ade-
quacy of staffing, adequacy of equipment/information/processes, and reporting
infrastructure.
3. Risk: this dimension includes questions about risk taking and willingness to ask
for help.
4. Work pressure: this dimension includes questions about work and production
pressure within a department that may be threats to patient safety.
5. Competence: this dimension includes questions about the adequacy of crisis
management.
6. Procedures/rules: this dimension includes questions about which and how errors
should be reported and to whom, compliance with rules and procedures.
7. Miscellaneous: this dimension includes questions about teamwork, communi-
cation openness, organizational learning, feedback and communication, beliefs
about causes of errors and adverse events, job satisfaction, and overall perceptions
of safety.
An empirical study with 632 employees from 46 hospital units examined relationships
between patient safety climate and medical treatment errors [269]. The authors con-
ceptualized safety climate as a multidimensional construct with four dimensions:
1. Safety procedures: employees’ shared perceptions of the level of detail in the
organization’s patient safety procedures (example questions: “In your unit, to
what extent are there many written procedures?” “In your unit, to what extent
are the safety procedures detailed?” “In your unit, to what extent are the safety
procedures extensive?”).
2. Safety information flow: employees’ shared perceptions of the amount of safety-
related information that they receive through routine circulation and training
(example questions: “In your unit, to what extent are employees informed about
many new updates of the safety rules and regulations?” “In your unit, to what
extent are the employees informed about potential hazards?” “In your unit, to
what extent are there many safety training programs?”).
3. Perceived managerial safety practices: employees’ shared perceptions of their
supervisors’ safety behaviors and methods (example questions: “In your unit,
does the unit head approach team members during work to bring safety issues to
their attention?” “In your unit, does the unit head monitor you more closely when
a team member violates a safety rule?” “In your unit, does the unit head create an
atmosphere in which people can say whatever they think about safety?”
4. Safety priority: employees’ shared expectations regarding the balance between
safety and other work requirements, such as productivity (example questions:
“In my unit, in order to get the work done, one must ignore some safety aspects”
(reverse coded), “In my unit, whenever pressure builds up, the preference is to do
the job as fast as possible, even if that means com promising on safety” (reverse
coded), “In my unit, it doesn’t matter how the work is done as long as there are no
accidents” (reverse coded).
The results of the study showed a curvilinear, or U-shaped, relationship between per-
ceived safety procedures and the number of medical treatment errors, and a positive
and linear relationship between perceived managerial safety practices and treatment
errors [269]. These relationships were influenced by perceived safety priority, such
that the relationships were weaker when perceived safety priority was high. Based
on their results, the authors of the study suggested that formal safety procedures and
practices are not sufficient to reduce treatment errors, but that employees’ indivi-
dual and shared perceptions of these procedures and their importance are important
factors that should be taken into consideration by organizational practitioners [269].
6.2.2 Measures of safety culture and climate
Numerous self-report surveys to assess patient safety culture and climate in

health care organizations exist in the literature. A systematic literature review
compared nine of these surveys in terms of their general characteristics, dimensi-

ons, as well as psychometric reliability and validity [270 ]. The review showed that
most surveys tapped into the following five dimensions of patient safety culture
and climate:
– Patient safety leadership
– Patient safety policies and procedures
– Staffing
– Patient safety communication
– Error reporting
Another systematic review of 12 quantitative studies that included measures of patient

safety culture and climate in the health care context concluded that several limita-
tions existed in the reviewed studies [271]. In particular, the authors noted that most
surveys were not based on explicit theoretical frameworks, that some studies did not
report psychometric criteria, and that those studies that reported psychometric crite-
ria has several flaws [see also 272].
In terms of specific surveys with good reliability (i.e., overall consistency of the
measure) and good validity (i.e., the extent to which a survey measures what it claims
to measure), the “Strategies for Leadership: An Organizational Approach to Patient
Safety” (SLOAPS, developed by VHA Inc.) survey is a general safety culture measure
with 58 questions that assesses the implementation of interventions at the organi-
zational level and whether patient safety is a strategic priority in the organization
[273]. That is, the survey is completed by managers and not individual employees. It
includes nine dimensions:
1. Leadership I: demonstrating patient safety as a top leadership priority.
2. Leadership II: promoting a non-punitive culture for sharing information and
lessons learned.
3. Strategic planning I: routinely conducting an organization wide assessment of the
risk of error and adverse events in the care delivery process.
4. Strategic planning II: actively evaluating the competitive/collaborative environ-
ment and identifying partners with whom to learn and share best practices in
clinical care.
5. Information and analysis: analyzing adverse events and identifying trends across
events.
6. Human resources I: establishing rewards and recognition for reporting errors and
safety driven decision making.
7. Human resources II: fostering effective teamwork regardless of a team member’s
position of authority.
8. Process management: implementing care delivery process improvements that
avoid reliance on memory and vigilance.
9. Patient and family involvement: engaging patients and families in care delivery,
workflow, process, design, and feedback.
The “Patient Safety Cultures in Health care Organizations” (PSCHO) survey has 32 items
and is completed by individuals [264, 274]. The survey measures five dimensions:
1. Organization: example statements are: “I am rewarded for taking quick action
to identify a serious mistake,” “good communication flow exists up the chain
of command regarding patient safety issues,” and “patient safety decisions are
made at the proper level by the most qualified people.”
2. Department: example statements are: “in my department, disregarding policy
and procedure is rare,” “my department follows a specific process to review
performance against defined training goals,” and “compared with other facilities
in the area, this facility cares more about the quality of patient care it provides.”
3. Production: example statements are: “I have witnessed a coworker do something
that appeared to me to be unsafe patient care,” “in the last year I have witnessed
a coworker do something that appeared to me to be unsafe for the patient in order
to save time, and “compared to other facilities in the area, this facility cares more
about increasing revenues or profits.”
4. reporting/seeking help: example statements are: “if people find out that I made a
mistake, I will be disciplined,” “reporting a patient safety problem will not result
in negative repercussions for the person reporting it,” and “if I see a problem with
the management of a patient, I would say something, even though it would makes
a senior person look bad.”
5. Shame/self-awareness: example statements are: “telling others about my mistakes
is embarrassing,” and “I have made significant errors in my work that I attribute
to my own fatigue.”
Additional patient safety culture and climate surveys identified in the systema-
tic review with satisfactory psychometric results (i.e., good reliability and validity)
include [270]:
1. The “Veterans Administration Patient Safety Culture Questionnaire” (VHA PSCQ),
a survey with 71 questions for individuals (13 dimensions).
2. The “Hospital Survey on Patient Safety” (HSOPS), a survey with 42 questions for
individuals (12 dimensions).
3. The “Safety Attitudes Questionnaire” (SAQ), which has 60 questions for individu-
als (six dimensions: teamwork, safety climate, perceptions of management, job
satisfaction, stress recognition, and working conditions).
4. The “Safety Climate Survey” (SCS), which has 19 items for individuals (one
dimension).
6.2.3 Antecedents of safety culture and climate
Several studies in the health care literature have investigated the antecedents or
predictors of employees’ individual or shared perceptions of their organization’s
patient safety culture or climate. With regard to organizational characteristics as pre-

dictors of patient safety culture and climate in health care, a study with data from
278 medical-surgical units in 143 hospitals investigated effects of the organizational
context (e.g., external influences) and organizational structure (e.g., working con-
ditions) on patient safety climate in acute care hospitals [275]. The results showed
that organizational context factors influenced the organizational structure of nursing
units that, in turn, influenced the units’ safety climates.
Consistent with the work and organizational psychology literature [276], manage-
ment and leadership characteristics appear to be important predictors of patient
safety culture and climate. For instance, a study with 248 registered nurses working
in a hospital in China found a strong association between management safety com-
mitment and patient safety culture [111]. The authors suggested that to create a posi-
tive safety culture, managers need to visibly commit to patient safety and act as role
models for their employees. Another study on patient safety climate in medical-
surgery units collected data from 3689 registered nurses in 286 medical-surgical units
in 146 hospitals [277]. The results of the study showed that unit leaders’ commitment
to patient safety positively influenced the patient safety climate in the units. However,
the study also found that nurse conflicts between job stressors and safety compli-
ance, as well as a general reluctance to discuss errors, were detrimental to the patient
safety climate. A third study with data from 455 employees working in four hospi-
tals in the United States confirmed that leadership commitment to patient safety is
an important predictor of employee perceptions of the existence of a patient safety
culture [278]. The study further showed that employees’ safety culture perceptions
negatively predicted harmful incidents.
In terms of individual employees’ demographic characteristics, research indica-
tes that health care professionals’ job status may affect perceptions of patient safety
climate. In a study with 432 employees from eight nursing homes in the United States,
safety climate perceptions varied significantly by job status [279]. Specifically, front-
line employees had less positive perceptions of the safety climate than their mana-
gers did. Another study with 6312 employees, supervisors, and senior managers from
15 hospitals in the United States confirmed the role of job status as a predictor of
patient safety culture [274]. The results of the study showed that a positive safety
culture generally did not exist in some of the hospitals, and that especially nurses and
front-line employees provided low ratings of safety culture compared to non-clinicians
and senior managers. The authors raised the interesting possibility of training senior
managers to transfer their commitment to safety to front-line employees successfully.
Finally, employee age may also play a role with regard to perceptions of patient safety
culture and climate. A study with 213 primary care staff from four air force ambulatory
clinics in the United States found that younger staff (aged 31 years and younger) had
lower scores on perceived safety climate and an overall measure of patient safety,
as well as related scales such as team work climate, management perceptions, and
job satisfaction [280]. The researchers suggested that organizational strategies and
interventions designed to improve patient safety could be specifically targeted at

organizational newcomers and younger employees.
Finally, employee characteristics other than demographics may also predict emplo-
yees’ perceptions of the extent to which their organization has a positive patient safety
culture or climate. For instance, a longitudinal study with approximately 7000 employees
working for a tertiary academic medical center found that high levels of employee
engagement were associated with a positive patient safety culture [281]. Another study
with 344 nurses in two hospitals found that nurses’ safety motivation, safety decision
making, safety communication, as well as perceptions of nursing unit leadership and
levels of nurses’ direct care hours influenced nurses’ patient safety culture perceptions
and, in turn, patient safety behaviors (including frequency of reporting medication
administration errors) [282].
6.2.4 Consequences of safety culture and climate
Health care researchers have conducted several studies to examine the outcomes of
organization-level patient safety cultures and climates as well as individual employee
perceptions of the extent to which a positive patient safety culture or climate exists
in their organization. Generally, the existence of positive patient safety cultures and
climates appears to be linked to both objective patient safety outcomes as well as sub-
jective experiences of patients and employees. For instance, a study with 1127 nurses
working in 42 randomly selected hospitals in the United States found that a positive
patient safety climate was associated with less medication errors, nurse back injuries,
and patient urinary tract infections [283]. The relationships between patient safety
climate on the one hand and both medication errors and nurse back injuries on the
other were influenced by the complexity of patient conditions. Specifically, the patient
safety climate had a stronger effect on these objective patient safety outcomes when
patient conditions were more complex. In addition, the study found that a positive
patient safety climate was associated with higher levels of patient and nurse satisfac-
tion with the quality of nursing care [283]. Another study with 194 nurses from two
hospitals in the United States investigated the combined effects of safety climate and
patient unpredictability on both objective and subjective patient safety outcomes:
employees’ occupational injuries and their perceived level of strain [284]. The results
of the study showed that in units with positive safety climates, there was a weaker
relationship between patient unpredictability and nurses’ occupational injuries and
strain, whereas the relationship was stronger in units with less positive safety clima-
tes. Finally, longitudinal research with more than 400 employees from a hospital in
Australia has shown that organizational safety climate influenced employees’ moti-
vation to behave in safe ways which, in turn, leads to changes in safe work behaviors
over time [8]. In addition, safety climate, safety motivation, and safety behavior were
associated with accidents over a period of 5 years.
Health care studies that focused only on rather objective patient safety outcomes
have generally confirmed the importance of positive patient safety cultures and cli-
mates. A study with data from employees in 91 hospitals examined relationships
between hospital safety climate and a number of objective patient safety indicators
[285]. Results showed that hospitals with a more positive safety climate generally
had a lower incidence of patient safety-related adverse events. Especially the safety
climate dimension “beliefs regarding shame and blame” had strong effects on indi-
cators. Frontline employees’ perceptions of safety climate were negatively related to
the risk of experiencing patient safety-related adverse events, whereas senior mana-
gers’ perceptions were not. Similarly, in a large-scale study of 56,480 employees from
179 hospitals, researcher examined relationships between hospitals’ patient safety
culture on the one hand and rates of in-hospital complications and adverse events
on the other [286]. The results indicated that a positive hospital patient safety culture
was associated with fewer in-hospital complications and adverse events. Finally, a
longitudinal study with 955 nurses working in 69 inpatient units of three hospitals
examined relationships between the hospital patient safety climate, unit-level patient
safety climate, and patient safety practices 6 months later [287]. Both hospital and
unit safety climates significantly predicted routine medication and emergency safety
scores. In addition, hospital and unit safety climates had an interactive effect on these
outcomes, such that the best safety outcomes were obtained when both hospital and
unit climates were positive. In addition, the results showed that a positive unit safety
climate can compensate for a less positive hospital safety climate. Finally, high levels
of safety climate strength increased the effects of both safety climates on routine
medication and emergency safety scores.
It is likely that the effects of patient safety culture and climate on objective patient
safety outcomes are explained (“mediated”) by subjective experiences and behaviors
of health care employees related to patient safety as well as the subjective experi-
ences of patients. In support of this assumption, research has shown that perceived
safety climate influences individual employees’ safety behavior, and that this effect
is explained by employees’ safety motivation, that is, the employees’ willingness to
invest effort in safety-related issues [31]. A study with data from employees working
in 73 hospitals in the United States examined the relationship between employee per-
ceptions of their organization’s patient safety culture and the experiences of patients
with hospital care and services [288]. The results showed that positive employee per-
ceptions of their hospital’s patient safety culture were associated with positive assess-
ments of care and services by patients. The findings of such individual studies are
confirmed by a recent meta-analysis on the antecedents of safety-related behaviors
and outcomes in a broad range of jobs and occupations [44]. Specifically, the meta-
analysis showed that team safety climate was strongly related with objective outco-
mes such as accidents and injuries. In addition, team safety climate was positively
related to employees’ safety motivation, safety knowledge, and safety behaviors. The
researchers suggested that these individual employees’ safety outcomes, in turn,

influence objective outcomes such as accidents and injuries.
6.2.5 Interventions to increase safety culture and climate
The results of surveys designed to assess health care organizations’ patient safety
culture or climate are not always as expected or desired by the organizations’ mana-
gers and administration. For example, in one study with employees from 40 nursing
homes, employees generally agreed that patient safety culture was poor [289]. The
authors of the study suggested that the low levels of patient safety culture might signi-
ficantly impact on the quality of care and, subsequently, the quality of life of residents.
Another study with 3940 employees working in five Belgian hospitals found that
employees’ perceptions of patient safety culture were “low to moderate” in all of the
hospitals [290]. The dimensions of patient safety culture with the lowest agreement
ratings were “hospital management support for patient safety” (35% agreement),
“non-punitive response to error” (36%), “hospital transfers and transitions” (36%),
“staffing” (38%), and “teamwork across hospital units” (40%). The only dimension
that had a relatively high score was “teamwork within hospital units.”
Organizations aiming to increase their patient safety culture and climate could
conduct interventions based on the empirical evidence provided by the patient safety
literature. For instance, an intervention study that aimed to enhance safety culture in
two children’s hospitals in the United States suggested conducting regular and spon-
taneous safety checks, improving the error self-report system, and introducing better
communication processes [291]. For the study, 394 employees working completed
safety culture surveys before and after the intervention. The results showed that the
intervention led to improvements in employees’ perceptions of supervisory responses
to errors as well as error communicating and error learning. Generally, to increase
their safety culture and climate, organizations could follow ten recommendations
based on the theoretical and empirical literature on the topics reviewed in this book:
1. Select employees and supervisors based on individual differences (e.g., conscien-
tiousness, emotional stability) as well as past behaviors (e.g., high patient safety
performance) that predict future patient safety performance.
2. Make patient safety performance a priority in the organization (e.g., by setting
specific and difficult patient safety goals and establishing a patient safety vision).
3. Regularly evaluate and reward high levels of patient safety performance and
other work behaviors that contribute indirectly to patient safety (e.g., high levels
of task, citizenship, proactive, and adaptive work performance).
4. Improve employees’ and supervisors’ safety knowledge, skills, abilities, and atti-
tudes using well designed (i.e., based on a thorough needs analysis) and well deli-
vered (i.e., based on psychological learning principles) safety training programs.
5. Design motivating jobs (e.g., by increasing employees’ perceived task significance)

and minimize job stressors (e.g., by reducing high workload and increasing auto-
nomy) that may impact on patient safety.
6. Provide sufficient organizational resources (time and funding) for safety, inclu-
ding a safety budget as well as formal roles of safety representatives and safety
committee members.
7. Increase organizational leaders’ safety motivation and commitment to patient
safety in order to influence employees’ patient safety self-efficacy and behavior.
8. Train employees and leaders in effective teamwork skills, including effective
communication and cooperation.
9. Involve patients in processes that concern their own safety by training health care
professionals to accept and facilitate patient participation and by educating and
motivating patients through effective communication.
10. Measure and report patient safety indicators on a regular basis, including objec-
tive and subjective outcomes as well as shared team and organizational level
climate and culture.
6.3 Summary
This chapter focused on organizational level influences on patient safety with a focus
on organizational culture and climate for patient safety. The most important insights
are summarized below.
1. Organizational patient safety culture refers to the implicit and shared beliefs, atti-
tudes, and values regarding patient safety of employees and leaders in health
care contexts.
2. Organizational patient safety climate refers to employees’ shared perceptions of
patient safety-related policies, practices, and procedures in the organization, or
“the way patient safety is addressed around here.”
3. Perceived or psychological cultures and climates of individual employees differ
from shared (and aggregated) organizational level cultures and climates.
4. While most existing research on patient safety culture and climate has not distin-
guished between culture and climate as well as psychological and organizational
culture/climate, numerous studies provide evidence for the effects of employees’
perceptions of patient safety in their organization on both employee and patient
outcomes.
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Index
Absenteeism 66, 76, 94 Counterproductive performance 19, 20, 48, 54,

Active failure 5 58, 108
Active listening 89 Crew Resource Management 79, 93
Adaptive performance 19, 20, 21, 64, 121 Crisis management 114
Affective events theory 52, 53, 54
Agreeableness 45, 46, 47 Decision making 2, 4, 5, 12, 17, 25, 26, 29, 30,
Attitudes 4, 5, 12, 17, 27, 42, 47, 48, 50, 51, 52, 31, 32, 33, 54, 58, 61, 64, 73, 79, 83, 86,
54, 58, 66, 67, 70, 74, 76, 77, 78, 79, 83, 94, 98, 104, 106, 111, 116, 119
86, 87, 90, 96, 98, 99, 100, 105, 111, 112, Declarative knowledge 22, 23
113, 122 Deep acting 57
Attitudes toward patient participation 82 Depersonalization 59
Autonomy 45, 47, 52, 55, 56, 61, 62, 65, Destructive leadership 108
66, 105, 122
Emotional exhaustion 5, 18, 59
Behavioral theories of leadership 103, 104 Emotional intelligence 46, 53, 55, 103
Beliefs 4, 39, 47, 49, 50, 76, 81, 99, 109, 111, Emotional labor 56, 57
112, 113, 114, 120, 122 Emotional stability 24, 45, 46, 47, 53, 55, 59, 121
Biases 30, 31, 32, 54, 111 Emotions 4, 17, 24, 30, 46, 47, 51, 52, 53, 54, 56,
Burnout 58, 59, 66 57, 64, 84, 98, 99
Business 1, 111 Equity theory 40, 41
Error management 51, 69, 70, 73, 100, 112
Challenge stressors 67 Ethical decision making 63
Chronic mood 47, 53, 54, 57, 95, 98 Expectancy theory 35
Circumplex model 51, 52 Experience 4, 5, 12, 13, 14, 17, 21, 25, 26, 27, 28,
Citizenship performance 19, 20, 21, 23, 30, 48, 91, 95, 100
54, 64, 121 Extraversion 45, 53
Cognitive ability 17, 23, 24, 25, 26, 29, 64, 74,
75, 103 Fatigue 5, 28, 52, 54, 56, 58, 73, 84, 117
Communicating errors 93 Feedback 36, 38, 39, 60, 65, 66, 71, 72, 74,
Communication 2, 3, 4, 5, 9, 11, 12, 15, 26, 33, 75, 76, 78, 79, 82, 83, 84, 89, 99, 101, 104,
51, 71, 73, 78, 79, 81, 82, 84, 87, 88, 89, 109, 110, 114, 116
90, 91, 92, 93, 94, 95, 98, 99, 100, 106, Fundamental attribution error 31
110, 114, 116, 117, 119, 121, 122
Communication breakdowns 25, 28, 91 Goal setting theory 36, 37
Communication failures 91, 92
Communication psychology 89 Hand hygiene 23, 36, 43, 44, 50, 86
Competencies 1, 25, 27, 28, 29, 78, 99 Heuristics 30, 31
Conflict management 79 Hierarchy of needs model 34
Conscientiousness 45, 46, 47, 57, 121 Hindrance stressors 67
Consideration 104, 108
Contingency theories of leadership 105 Iatrogenic harm 1
Contributing factors 5, 9, 10, 11 Identity threat 97, 98
Control theory 39, 40 Impact theories 11, 12
Coping 28, 29, 59, 60, 61 Individual differences 4, 17, 18, 22, 24, 26, 27,
Core self-evaluations 46 33, 37, 46, 53, 60, 64, 96, 103, 121
138 Index
Initiating structure 104 Occupational health psychology 54

Input-process-output model of team Openness to experience 45
Functioning 94 Operant conditioning 39
Interests 20, 42, 43, 102, 107, 108 Organizational climate 63, 69, 111, 112
International patient safety classification 7 Organizational commitment 48,
Interpersonal processes 4, 81, 83, 110 52, 114
Interventions 37, 40, 51, 62, 63, 71, 82, 86, 87, Organizational culture 5, 11, 13, 60, 85, 111,
94, 100, 101, 103, 109, 110, 116, 119, 121 112, 122
Organizational justice 40, 41
Job characteristics model 65, 66
Job control 61, 62 Participative leadership 106
Job demands 25, 56, 61, 62 Patient participation 4, 81, 82, 83, 84, 85,
Job demands-control model 61, 62 86, 87, 110, 122
Job design 3, 4, 5, 44, 65, 66, 80 Patient safety attitude 4, 49, 50, 51, 52, 54, 55,
Job satisfaction 45, 47, 48, 52, 66, 108, 114, 64, 67, 86
117, 118 Patient safety climate 111, 113, 114, 117, 118,
119, 120, 121, 122
Knowledge 3, 4, 5, 13, 17, 18, 22, 23, 24, 25, Patient safety culture 4, 28, 109, 111, 113, 114,
26, 27, 28, 29, 31, 32, 46, 59, 64, 66, 67, 116, 117, 118, 119, 120, 121, 122
70, 72, 74, 76, 77, 78, 79, 81, 82, 84, 90, Patient satisfaction 18, 33, 37, 76, 88,
95, 96, 101, 106, 110 89, 108
Perceived behavioral control 49, 50, 63
Latent failure 5 Perceived impact on patients 44
Leader-member exchange 105, 106 Personality 4, 5, 17, 22, 23, 24, 45, 46, 47, 53,
Leadership 2, 3, 4, 5, 11, 13, 26, 33, 69, 71, 81, 57, 64, 95, 96, 103
85, 94, 95, 99, 100, 101, 102, 103, 104, 105, Proactive performance 19, 21, 48, 64, 121
106, 108, 109, 111, 116, 118, 119 Procedural knowledge 22, 26
Learning 12, 13, 14, 20, 26, 28, 32, 37, 38, 67, Process theories 11, 12, 35
68, 70, 71, 72, 73, 74, 75, 76, 77, 78, 80, Productivity 18, 19, 95, 115
104, 109, 114, 121 Professional commitment 48
Psychological contract 58
Management 5, 41, 73, 85, 95, 101, 102, 103, Psychological safety 63, 99
114, 117, 118 Psychology 1, 2, 17, 24, 29, 30, 33, 38, 46, 54,
Management support 50, 69, 72, 78, 121 67, 74, 103
Mastery experiences 37, 38 Psychometrics 17, 116, 117
Maximum work performance 23
Meaningfulness 58, 66, 80, 95 Quality management 13
Mitigating factors 9, 10, 11 Quality of care 29, 41, 48, 49, 67, 69, 70,
Motivation 12, 17, 22, 23, 26, 27, 33, 34, 35, 36, 72, 76, 77, 81, 87, 94, 95, 98, 101,
39, 40, 42, 44, 59, 64, 68, 72, 75, 80, 82, 108, 121
84, 97, 98, 102, 107, 108
Multi-disciplinary teams 94 Rational choice 30
Multilevel framework 3, 4, 5, 6 Reinforcement theory 38, 39
Multitasking 57 Resources 5, 10, 19, 20, 25, 30, 52, 55, 56, 59,
60, 61, 69, 72, 77, 78, 79, 94, 95, 96, 101,
Needs 34, 35, 48, 69, 70, 74, 80, 107, 121 106, 114, 116, 122
Neuroticism 45, 53, 57 Responsibility 5, 27, 29, 46, 56, 66, 82, 83, 84,
Norms 20, 30, 42, 43, 49, 50, 63, 76, 108, 112, 113 94, 102, 107, 114
Index 139
Safety attitude 2, 14, 38, 52, 53, 70, 71, 76, 79, Survey measures 14, 26, 76
86, 109, 110, 111, 117, 121 Systems perspective 4, 5
Safety commitment 106, 118
Safety compliance 21, 51, 67, 73, 89, 114, 118 Task identity 65, 66
Safety knowledge 4, 15, 25, 26, 34, 38, 45, 46, Task performance 19, 20, 21, 64, 121
67, 68, 70, 71, 76, 120, 121 Task significance 43, 44, 47, 65, 66,
Safety motivation 4, 26, 33, 34, 35, 36, 80, 122
38, 42, 43, 44, 45, 46, 66, 80, 100, Team composition 94, 95, 96
110, 119, 120, 122 Team coordination 5, 79, 95, 99, 100
Safety norms 49, 50 Team coordination training 78
Safety participation 21 Team cross-training 78
Safety performance 19, 21, 22, 25, 26, 33, 34, Team diversity 95, 96, 97, 98, 110
35, 37, 38, 42, 43, 64, 66, 68, 71, 80, 95, Team leadership training 79
96, 97, 100, 110, 121 Team learning 99
Safety skills 25, 26, 38, 67, 71, 121 Team performance 79, 91, 95, 96, 98,
Scientist-practitioner model 2 99, 100, 104
Self-affirmation bias 18 Team self-correction training 79
Self-efficacy 37, 38, 46, 59, 64, 75, 82, Team training 2, 77, 78, 79, 80, 92, 93, 95
87, 110, 122 Theories of change 12
Self-fulfilling prophecy 38 Theory of planned behavior 48, 49, 50, 63
Shared decision making 32, 33 Time pressure 23, 30, 36, 54, 56, 57, 67, 93
Simulation-based training 71, 72 Training 3, 4, 5, 11, 15, 21, 24, 25, 26, 34, 37,
Skills 4, 17, 22, 23, 24, 25, 26, 27, 32, 54, 59, 38, 40, 51, 54, 58, 63, 65, 67, 68, 69, 70,
61, 64, 65, 67, 70, 71, 72, 74, 76, 77, 78, 71, 72, 74, 80, 82, 86, 90, 94, 100, 101,
79, 84, 86, 90, 95, 96, 100, 101, 106, 122 103, 114, 115, 117, 118, 121, 122
Skills training 76 Training design 69, 70, 71, 78
Skill variety 65, 66 Training evaluation 69, 70, 73, 76, 77
Social categorization 96, 97, 98, 110 Training needs analysis 69, 70, 72
Social categorization and information Training objectives 69, 70
elaboration model of team diversity 96 Training performance 24, 75
Social cognitive theory 37 Training transfer 68, 74, 77, 78
Social identification 42 Trait theories of leadership 103
Social identity theory 42 Transactional leadership 60, 62, 107, 108
Social motivation 42, 43, 44 Transactional stress model 61
Social persuasion 37, 38 Transfer climate 68, 72, 73, 77
Social support 55, 59, 60, 62, 66 Transformational leadership 107, 108, 110
Staffing 18, 21, 29, 55, 85, 101, 103, 114, Turnover 56, 58, 66, 94, 108
116, 121 Typical work performance 23
Stages of change theories 11, 12
Storytelling 73 Values 27, 30, 42, 100, 102, 107, 108,
Strain 55, 56, 57, 58, 61, 59, 60, 61, 62, 109, 111, 112, 113, 122
64, 119 Vicarious learning 37, 38
Stress 3, 4, 5, 17, 20, 21, 38, 54, 55, 57, 59, 60,
61, 63, 79, 93, 108, 117 Well-being 2, 4, 7, 8, 17, 20, 45, 46, 55, 57,
Stress management 51, 59, 62, 63 58, 59, 60, 64, 88, 95, 100, 108
Stressors 28, 55, 56, 57, 58, 59, 60, 62, Work and organizational psychology 2, 24,
63, 118, 122 27, 41, 46, 52, 63, 65, 67, 94, 98, 99,
Surface acting 57 102, 103, 107, 111, 112, 113, 118
140 Index
Work characteristics 52, 53, 54, 66, 67 48, 57, 59, 64, 66, 67, 68, 70, 72, 74, 75,
Work events 52, 53 76, 78, 80, 92, 94, 107, 108
Work experience 26, 27 World Alliance for Patient Safety 7, 8, 9,
Workload 5, 25, 28, 50, 54, 56, 61, 122 11, 81
Work motivation 33, 34, 35, 36, 40, 42, 43, 44, 66
Work performance 2, 17, 18, 19, 20, 21, 22, 23, Yorkshire Contributory Factors Framework
24, 25, 26, 28, 33, 36, 37, 40, 45, 46, 47, 5, 15

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Hannes Zacher

Patient Safety – A Psychological Perspective

The book has 21 figures and 4 tables.

Library of Congress Cataloging-in-Publication Data

Bibliographic information published by the Deutsche Nationalbibliothek

© 2014 Walter de Gruyter GmbH, Berlin/Boston.

Typesetting: Compuscript Ltd., Shannon, Ireland

Brisbane, September 2013

2 Patient safety: definitions, theories, and measurement 7

3 Individual level influences on patient safety 17

3.8.5 The job demands-control model 61

4 Job level influences on patient safety 65

5 Interpersonal and team level influences on patient safety 81

6 Organizational level influences on patient safety 111

6.2.4 Consequences of safety culture and climate 119

1.1 Purpose of this book

A psychological perspective on patient safety is an important addition to other

1.2 A multilevel framework of patient safety

Health care context Latent

Fig. 1.1: A multilevel framework of factors influencing patient safety

employees report errors to their managers. Alternatively, individual employees may

1.3 Organization of this book

2.1 Definitions of concepts relevant to patient safety

Patient A person who is a recipient of health care.

2.2 Conceptual framework of patient safety

In addition to providing a comprehensive set of patient safety concepts and defi-

Patient characteristics Incident type Incident characteristics

Patient outcomes Organizational outcomes

influenced by contributing factors and hazards, detection, mitigating factors, patients

2.3 Measurement of patient safety outcomes

Health care researchers and practitioners have developed different methods to

Type of theories Description

Focus Type of theories Description

Individuals Cognitive theories Cognitive theories focus on the decision making

Focus Type of theories Description

Social network and Social network and influence theories focus on

Other researchers have developed and validated complex tests to measure

3.1 Work behavior and performance

Psychologists are interested in understanding, predicting, and possibly changing

3.1.1 Dimensions of work performance

Work performance is not a homogeneous construct but consists of multiple distinct

Citizenship (or contextual) performance involves discretionary and not required

– Demonstrating cultural adaptability

3.1.2 Theories of work performance

In their theorizing, work and organizational psychologists have proposed that

Individual differences, such as cognitive abilities and personality characteristics, as

Job, team, and

Fig. 3.1: Influences on work behavior and performance

work performance). It is important to keep in mind that health care professionals’

research in work and organizational psychology as well as in patient safety research.

suggested by the psychological literature, cognitive ability is likely to be an important

3.3 Knowledge, skills, experience, and competencies

As suggested by theoretical models of work performance, employees’ safety-related

of safety knowledge positively predicted important safety performance factors,

4. Analyzing and interpreting: this competency involves clear thinking, grasping

In contrast to cognitive ability, decision making is a more or less conscious cognitive

3.4.1 Heuristics and biases in decision making

Psychological research on heuristics assumes that, over the course of thousands of

3.4.2 Shared decision making

Safety performance = (safety ability × safety motivation)

This equation indicates that if an employees’ ability to maintain high levels of

3.5.1 Need theories of motivation

According to the hierarchy of needs model, a lower-order need has to be satisfied

Perception of the Perception of the Perception of the