Safety culture has risen to prominence over the past two decades as a means by which organisations may enhance their safety performance. Safety culture may be conceptualised as an interpretive device that mediates between organisational safety rhetoric and safety programs on the one hand, and local workplace cultures on the other. More recently, risk-awareness has emerged as a cultural approach to safety. Front line workers are encouraged to become risk-aware through programs designed to prompt them to undertake mental or informal risk assessments before commencing work. The problem is that risk-awareness programs have not been the subject of systematic research and the impact of these programs on the culture of safety and the resultant level of risk is unknown. Therefore, this ethnographic study of two sites within a large contract maintenance organisation in Australia explored what impact risk-awareness programs have upon the culture of safety and the resultant level of risk. The researcher spent two months in the field and data was collected through participant observation, semistructured interviews and through a review of organisational documents. This study found that managers focused upon collecting the paperwork associated with the program as proof that workers had a safer workplace, whereas workers preferred to rely upon their common sense rather than the paperwork to keep them safe. As a consequence, the riskawareness program resulted in a culture of paperwork and varying levels of risk reduction because the paperwork associated with the program created an illusion of safety for managers as much as common sense did for workers. The results of this study have implications for safety culture, risk-awareness programs and for organisational learning. They also have implications for organisations wishing to improve their safety culture by encouraging risk-awareness in front-line workers. / Doctor of Philosophy

Safety culture has risen to prominence over the past two decades as a means by which organisations may enhance their safety performance. Safety culture may be conceptualised as an interpretive device that mediates between organisational safety rhetoric and safety programs on the one hand, and local workplace cultures on the other. More recently, risk-awareness has emerged as a cultural approach to safety. Front line workers are encouraged to become risk-aware through programs designed to prompt them to undertake mental or informal risk assessments before commencing work. The problem is that risk-awareness programs have not been the subject of systematic research and the impact of these programs on the culture of safety and the resultant level of risk is unknown. Therefore, this ethnographic study of two sites within a large contract maintenance organisation in Australia explored what impact risk-awareness programs have upon the culture of safety and the resultant level of risk. The researcher spent two months in the field and data was collected through participant observation, semistructured interviews and through a review of organisational documents. This study found that managers focused upon collecting the paperwork associated with the program as proof that workers had a safer workplace, whereas workers preferred to rely upon their common sense rather than the paperwork to keep them safe. As a consequence, the riskawareness program resulted in a culture of paperwork and varying levels of risk reduction because the paperwork associated with the program created an illusion of safety for managers as much as common sense did for workers. The results of this study have implications for safety culture, risk-awareness programs and for organisational learning. They also have implications for organisations wishing to improve their safety culture by encouraging risk-awareness in front-line workers. / Doctor of Philosophy

Thesis (Ph.D. in Nursing) -- University of Colorado Denver, 2007. / Typescript. Includes bibliographical references (leaves 93-101). Free to UCD affiliates. Online version available via ProQuest Digital Dissertations;

Thesis (Ph. D.)--Virginia Commonwealth University, 2005. / Prepared for: Dept. of Health Administration. Bibliography: leaves 202-251. Also available online.

Devido aos altos índices de acidentes do trabalho nas atividades de distribuição de energia elétrica, é imprescindível o empenho em aprimorar seus sistemas de gestão de segurança e saúde do trabalho. Nesse setor, bem como em outros, o desempenho em segurança é normalmente medido reativamente através de índices de acidentes, abordagem que vem sendo questionada pelos pesquisadores da área, que propõem que seja enfocada a variabilidade do trabalho real. Assim, emerge a premissa de que a gestão de segurança e saúde do trabalho deve estar imersa em uma cultura de informação, onde o sistema de relatos de incidentes se apresenta como ferramenta. É nesse contexto que é apresentado esse estudo realizado em uma concessionária de distribuição de energia elétrica no Rio Grande do Sul. A pesquisa tem por objetivo principal contribuir com a prevenção de acidentes sob uma perspectiva pró-ativa, através da proposição de diretrizes para o projeto, implantação e avaliação de um sistema de relatos de incidentes. A estratégia adotada para condução do estudo foi a pesquisa-ação, o que possibilitou aferir o processo envolvido na implementação do sistema. Durante a fase de projeto, que ocorreu de agosto a setembro de 2009, os pesquisadores em conjunto com membros da empresa determinaram as diretrizes fundamentais de operação do sistema, assim como adaptaram o formulário de relatos de acordo com a realidade da empresa estudada. Na última semana de setembro de 2009 teve início a etapa de implantação do sistema de relatos de incidentes, através de um estudo piloto com duas das sete equipes de eletricistas envolvidas no estudo, precedido por uma capacitação para o uso do sistema. Em meados de dezembro, o sistema de relatos foi estendido para todo o departamento envolvido no estudo e foi conduzido pela equipe de pesquisa até maio de 2010. A etapa de avaliação do sistema ocorreu através de entrevistas, em agosto de 2010 e março de 2011, com membros da empresa envolvidos no estudo, assim como por observações em campo durante toda a pesquisa. Durante a implantação do sistema de relatos de incidentes e a análise dos dados gerados, foi possível aprofundar a compreensão acerca da variabilidade do cenário em que os eletricistas desempenham suas tarefas, assim como identificar ações corretivas prioritárias. Como principais resultados podem ser citadas a prevalência de estruturas fora de padrão como agentes causadores dos incidentes e a influência do ambiente externo na atividade dos eletricistas. Por fim, foi analisado como um sistema de relatos de incidentes pode favorecer os princípios da engenharia de resiliência. / Due to high rates of occupational accidents in the electricity distribution´s activities, an effort is necessary to improve their safety and occupational health management. In this sector, as well as in others, the safety performance is normally measured by reactively accident rates, an approach that has been questioned by researchers, which propose to focus on the variability of the real work. Thus emerges the premise that the safety and occupational health management should be immersed in an information culture, where the incident reporting system is presented as a tool. This is the context of this study, realized in a company of electric energy distribution at Rio Grande do Sul. The research aims at contributing to the prevention of accidents with a proactive approach, by proposing guidelines for design, implementation and evaluation of an incident reports system. The strategy adopted for conducting the study was action research, enabling to assess the process involved in implementing the system. During the project, which occurred from August to September 2009, researchers and members of the company determined the basic orientation of the system operation, as well as adapted the reports form in accordance to the reality of the company. In the last week of September 2009 began the implantation phase of the incident report system, through a pilot study with two of the seven teams of electricians involved in the study, preceded by training. In December, the reporting system was extended to the entire department involved in the study and was lead by the research team until May 2010. The evaluation phase of the system occurred through interviews, in August 2010 and March 2011, with members of the company involved in the study, as well as field observations throughout the research. During the system´s implantation and analysis of data generated, it was possible to deepen the understanding of the variability of the scenario in which the electricians perform their tasks, as well as to identify priorities for corrective actions. Prevalence of non-standard structures as causative agents of the incidents and the influence of external environment on the activity of the electricians were the main results. Finally, it was analyzed how an incident reports system may favor the principles of resilience engineering.

A presente pesquisa identifica fatores protetores e não-protetores de trabalhadores petroquímicos, tendo como base o modelo de gestão praticado por uma empresa petroquímica – multinacional brasileira situada no Polo de Triunfo-RS – e seus reflexos na gestão da Saúde e Segurança do Trabalho. Para atender a esse propósito, o trabalho fundamenta sua teoria em: 1) sociedade líquido-moderna, 2) trabalho imaterial e a gestão, 3) governança corporativa e 4) gestão da saúde e segurança do trabalho. O método adotado é um estudo de caso único, de cunho qualitativo e de natureza exploratório – descritiva. Utiliza-se a triangulação de dados para o desenvolvimento desta pesquisa, baseada em sete entrevistas semiestruturadas, dados da empresa e outras fontes. Como resultado deste estudo, evidencia-se que a organização adota a governança corporativa como modelo de gestão, implicando na diminuição da hierarquia e na responsabilização de cada trabalhador pelo alcance das metas. Nesta condição, identificam-se elementos contraditórios que servem tanto para proteção quanto para não proteção os trabalhadores. Como fator protetor, a autonomia e a cooperação surgem, oportunamente, no poros do trabalho prescrito para aproximar os trabalhadores. Assim como a gestão da saúde e segurança do trabalho, que é reforçada por elementos técnicos e legais que possibilitam a manutenção das suas práticas, mesmo que feita por outras áreas (produção, manutenção etc). Um fator nãoprotetor é associado a gestão de si, característico da busca da cultura de interdependência, potencializado pelas práticas da gestão. O outro fator negativo é a negação dos perigos e o exagerado desejo de calcular os riscos, impactando em remunerações adicionais pela sua aceitação. / Based on the model of governance practiced by a petrochemical company, the present study identifies protective and non-protective factors from petrochemical workers and their reflections in health and safety management. The analised company is a Brazilian multinational located in Triunfo-RS. To fulfill this purpose, the study incorporates the follow subjects: 1) liquid-modern society, 2) immaterial labor and management, 3) corporate governance and 4) health and safety management. The method adopted is a single case study with a qualitative and exploratorydescriptive approach. Data triangulation was applied in this research, based on seven semi-structured in-depth interviews, data from the company and another sources. As a result of this study, it was shown that the company adopts corporate governance as a management model, resulting in the reduction of hierarchy and selfresposibilization of employees for goals achievement. In this condition, we identify contradictory elements which serve both for protection and for failing to protect workers, characteristic of managerialism. Autonomy and cooperation emerges in the pores of the prescribed work to put the workers together. The management of health and safety is enhanced by technical and legal elements that enable the maintenance of their practices, even if made by other areas (production, maintenance, etc.). A non-protective factor is associated with self-management, characteristic of the search for culture of interdependence, enhanced by management practices. The other negative factor is the health and safety hazards and the negation of the exaggerated desire to calculate the risks, impacting on additional remuneration for their acceptance.

Tendo em vista a crescente disseminação de sistemas de gestão da segurança e saúde no trabalho (SGSST), torna-se cada vez mais relevante a necessidade de instrumentos de avaliação da sua eficiência e eficácia. Nesse contexto, esta tese apresenta a proposta de um método de avaliação de sistemas de gestão de segurança e saúde no trabalho (MASST), o qual apresenta duas características inovadoras: a) a conciliação das abordagens estrutural (sistema prescrito), operacional (o que está acontecendo na prática) e por desempenho (resultados de indicadores); b) a adoção do enfoque da engenharia de resiliência (ER) sobre a segurança e saúde. O MASST foi desenvolvido a partir das contribuições da literatura, na qual foram identificados quatro princípios da ER (comprometimento da alta direção, flexibilidade, aprendizagem e consciência), bem como de um estudo de caso exploratório realizado em uma empresa de implementos agrícolas. Com base nisso, foram propostos vinte e sete itens distribuídos ao longo de sete critérios. Cada item possui um conjunto de requisitos que são avaliados com base em três fontes de evidências básicas: entrevistas, análise de documentos e observação direta. O MASST foi validado em um estudo de caso em uma empresa da cadeia automotiva. Os principais resultados revelaram que, no estudo de caso, em uma escala de pontuação de 0% a 100%, nove dentre quatorze itens relacionados à ER obtiveram pontuação entre 0% e 10%. Além disso, o MASST possibilitou a identificação dos pontos positivos do SGSST, a identificação das causas sistêmicas da falta de segurança e a identificação das prioridades de ação em termos de SST. Dentre as limitações do MASST percebidas durante o estudo de caso, salienta-se a necessidade de experiência do auditor acerca de conceitos e princípios da ER, os quais ainda não são amplamente aplicados de modo sistemático no meio industrial. / Due to the increasing dissemination of health and safety management systems (HSMS), both academics and practitioners have paid more attention to the assessment of their effectiveness and efficacy. This thesis introduces a method for assessing health and safety management systems (MASST) that has two innovative characteristics: a) it takes into account simultaneously the structural approach (prescribed system), the operational approach (what is really happening on the shop floor) and the performance approach (results of performance indicators); b) it adopts the resilience engineering (RE) perspective on health and safety. The MASST was developed based on both the literature review and an exploratory case study in a heavy machinery manufacturer. The literature review pointed out four major resilience engineering (RE) principles: top management commitment, flexibility, learning and awareness. Then, twenty-seven items grouped into seven major criteria were proposed. Each item encompasses a set of requirements that should be assessed based on three major sources of evidence: interviews, analysis of documents and direct observation. The MASST was tested in a case study that was carried out in a supplier of the automotive industry. The results pointed out that, considering a scale from 0% to 100%, nine out of the fourteen items related to the RE obtained a very low degree, ranging from 0% to 10%. Moreover, the MASST pointed out the positive aspects of the HSMS, identified systemic causes of the lack of safety and identified priorities in terms of health and safety management. The case study results also indicated that one of the main limitations of the MASST concerns the necessity of experienced auditors in terms of RE principles and concepts. This drawback is relevant since the RE perspective on health and safety has not yet been adopted by a large extent in the industry.

Nurses have a key role in keeping patients safe from medical errors because they work at the point of care where most errors occur. Nursing work at the intersection of patients and health care systems requires high levels of cognitive activity to anticipate potential problems and effectively respond to rapidly evolving and potentially harmful situations. The literature describes nursing work at the intersection of patient and health care system as well as barriers to providing safe patient care. However, little is known about the systems knowledge nurses use to negotiate the health care system on their patients’ behalf, or how this systems information is exchanged between nurses. Using the clinical microsystem as the conceptual framework, this qualitative descriptive investigation identified and described: 1) the components of systems knowledge needed by nurses, 2) how systems information is exchanged between nurses, and 3) systems information exchanged between staff nurses and travel nurses. Data were collected from a stratified maximum variation sample of 18 nurse leaders, staff nurses, and travel nurses working within a high-functioning neonatal intensive care nursery within a large academic medical center in New England. Data collection methods included participant observation, document review, individual interviews, and a focus group session. Data were analyzed through constant comparison for emerging themes and patterns. Findings were compared for commonalities and differences within and across groups. Three components of systems knowledge emerged: structural, operational, and relational. Systems information exchange occurred through direct and indirect means. Direct means included formal and informal mechanisms. The formal mechanism of orientation was identified by each participant. Informal mechanisms such as peer teaching, problem solving, and modeling behaviors were identified by participants from each of the three nurse groups. Travel nurses’ descriptions of the common themes focused on individual efficacy. Staff nurses focused on fostering smooth unit functioning. Nurse leaders described common themes from a perspective of unit development. Four overarching domains of systems information were exchanged between staff nurses and travel nurses: practice patterns; staffing patterns and roles; tips, tricks, tidbits, and techniques; and environmental elements. Communication emerged as a common theme across nurse groups and domains of systems information exchanged. These findings have implications for nursing orientation and staff development, continuous improvement at the local level, and curriculum development.

A busca por alimentos saudáveis, seguros e sustentáveis tem levado a um grande aumento do consumo de alimentos orgânicos, em todo o mundo. Embora esses alimentos sejam claramente menos expostos aos perigos químicos, diversos estudos têm demonstrado contaminação microbiológica significativa em produtos como as alfaces orgânicas, as quais são amplamente comercializadas. Dessa forma, o objetivo deste estudo foi avaliar a cadeia produtiva de alfaces orgânicas no sul do Brasil, através de análises microbiológicas e dos sistemas de gestão da inocuidade, buscando identificar possíveis medidas de intervenção a partir do ponto de vista da segurança dos alimentos. Três propriedades rurais de alface orgânica foram analisadas, utilizando as ferramentas Horticultural Assessment Scheme (HAS) e Horticulture Safety Management System Diagnosis (HSMS-DI). Amostras de adubo, solo adubado, mudas de alface, alface, água de irrigação e lavagem foram coletadas ao longo da cadeia produtiva, seguindo a ordem de inicio do plantio, durante o crescimento e na colheita das alfaces. As análises microbiológicas foram realizadas segundo o protocolo do HAS e normas internacionais. Para avaliação dos sistemas de gestão de segurança dos alimentos a ferramenta de diagnóstico HSMS-DI, com 58 questões, foi aplicada em cada propriedade rural. As Informações obtidas no HAS e HSMS-DI foram combinadas e um diagnóstico de cada propriedade foi elaborado, assim como foram sugeridas medidas de intervenção. Os resultados do HSMS-DI indicaram que as propriedades rurais apresentavam clara organização e forte embasamento quanto à prevenção dos riscos químicos, no entanto estavam operando em um contexto de risco microbiológico moderado a elevado. Os resultados obtidos com o HAS demonstraram contaminação por microrganismos de origem fecal em diversas amostras, além disso, foi detectada a presença de E. coli O157:H7 na água de irrigação e lavagem das alfaces, e a presença de Salmonella em adubo. Estes resultados demonstraram a existência natural e inerente de fontes de contaminação microbiológica na cadeia de produção de alfaces orgânicas. Contudo, destaca-se a necessidade de maior apoio aos produtores orgânicos, principalmente na implementação de medidas de controle da compostagem dos adubos e na qualidade da água de irrigação e lavagem dessas propriedades. / The search for healthy, safe and sustainable food has led to a large increase in the consumption of organic foods worldwide. Although these foods are clearly less exposed to chemical hazards, several studies have demonstrated significant microbial contamination in products such as organic lettuces, which are widely marketed. Thus, the aim of this study was to evaluate the production chain of organic lettuce in southern Brazil, through microbiological analyses and safety management systems in order to identify potential measures from the point of view of food safety. Three rural properties of organic lettuce were analyzed using the Horticultural Assessment Scheme (HAS) and the Horticulture and Safety Management System Diagnosis (HSMS-DI) tools. Samples of compost, fertilized soil, lettuce seedlings, lettuce, irrigation and wash water were collected along the production chain, following the beginning of the planting, the growing and the harvesting of lettuce. Microbiological analyzes were performed according to protocol HAS and international standards. For evaluation of the food safety management, the diagnostic tool HSMS-DI, with 58 questions, was administered to each farm. Information collected on HAS and HSMS-DI was combined and a diagnosis of each property was developed, as were suggested intervention measures. The results of the HSMS-DI indicate that the farms had clear and strong organizational foundation for the prevention of chemical risks, however, were operating in a context of moderate to high microbiological risk. The results obtained with the HAS showed contamination by microorganisms of fecal origin in several samples, furthermore, we detected the presence of E. coli O157: H7 in irrigation and wash water, and the presence of Salmonella in manure. These results demonstrated the existence of inherent and natural sources of microbiological contamination in the production chain of organic lettuces. However, there is a need for greater support for organic producers, especially in the implementation of control measures for fertilizer composting and in the quality of irrigation and wash water of these properties.

Tendo em vista a crescente disseminação de sistemas de gestão da segurança e saúde no trabalho (SGSST), torna-se cada vez mais relevante a necessidade de instrumentos de avaliação da sua eficiência e eficácia. Nesse contexto, esta tese apresenta a proposta de um método de avaliação de sistemas de gestão de segurança e saúde no trabalho (MASST), o qual apresenta duas características inovadoras: a) a conciliação das abordagens estrutural (sistema prescrito), operacional (o que está acontecendo na prática) e por desempenho (resultados de indicadores); b) a adoção do enfoque da engenharia de resiliência (ER) sobre a segurança e saúde. O MASST foi desenvolvido a partir das contribuições da literatura, na qual foram identificados quatro princípios da ER (comprometimento da alta direção, flexibilidade, aprendizagem e consciência), bem como de um estudo de caso exploratório realizado em uma empresa de implementos agrícolas. Com base nisso, foram propostos vinte e sete itens distribuídos ao longo de sete critérios. Cada item possui um conjunto de requisitos que são avaliados com base em três fontes de evidências básicas: entrevistas, análise de documentos e observação direta. O MASST foi validado em um estudo de caso em uma empresa da cadeia automotiva. Os principais resultados revelaram que, no estudo de caso, em uma escala de pontuação de 0% a 100%, nove dentre quatorze itens relacionados à ER obtiveram pontuação entre 0% e 10%. Além disso, o MASST possibilitou a identificação dos pontos positivos do SGSST, a identificação das causas sistêmicas da falta de segurança e a identificação das prioridades de ação em termos de SST. Dentre as limitações do MASST percebidas durante o estudo de caso, salienta-se a necessidade de experiência do auditor acerca de conceitos e princípios da ER, os quais ainda não são amplamente aplicados de modo sistemático no meio industrial. / Due to the increasing dissemination of health and safety management systems (HSMS), both academics and practitioners have paid more attention to the assessment of their effectiveness and efficacy. This thesis introduces a method for assessing health and safety management systems (MASST) that has two innovative characteristics: a) it takes into account simultaneously the structural approach (prescribed system), the operational approach (what is really happening on the shop floor) and the performance approach (results of performance indicators); b) it adopts the resilience engineering (RE) perspective on health and safety. The MASST was developed based on both the literature review and an exploratory case study in a heavy machinery manufacturer. The literature review pointed out four major resilience engineering (RE) principles: top management commitment, flexibility, learning and awareness. Then, twenty-seven items grouped into seven major criteria were proposed. Each item encompasses a set of requirements that should be assessed based on three major sources of evidence: interviews, analysis of documents and direct observation. The MASST was tested in a case study that was carried out in a supplier of the automotive industry. The results pointed out that, considering a scale from 0% to 100%, nine out of the fourteen items related to the RE obtained a very low degree, ranging from 0% to 10%. Moreover, the MASST pointed out the positive aspects of the HSMS, identified systemic causes of the lack of safety and identified priorities in terms of health and safety management. The case study results also indicated that one of the main limitations of the MASST concerns the necessity of experienced auditors in terms of RE principles and concepts. This drawback is relevant since the RE perspective on health and safety has not yet been adopted by a large extent in the industry.