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This thesis offers a commentary on the use of an embedded approach to explore variables impacting on employee safety culture at a large manufacturing plant. A mixed method approach was adopted in order to assess the safety culture of the company. The assessment stage consisted of point-of- work observations; unstructured individual interviews, semi-structured focus groups and a safety culture survey. This afforded a detailed insight into a rich array of context-specific variables impacting on employee perceptions of safety in the company, referenced to leadership style, incident reporting, rule breaking / risk taking, time pressure, communication and reactive approach to addressing safety issues. The safety culture assessment was followed by the development and implementation of two safety culture improvement programmes (interventions). Two matched pairs of departments (two experimental and two control) were chosen in which to conduct the interventions. The first intervention comprised a replication (with enhancements) of Zohar’s (2003) safety climate improvement intervention. The results indicated that low trust towards the management and the researcher, the face validity of the intervention, negative past experiences, insufficiently transparent communication and alienation engendered a high resistance to change. Seeking to address the shortcomings of the first, the second intervention represented a more organic approach, in which the improvement programme was designed to mesh with and complement established quality management systems. An improvement in employee safety performance was observed in the first month following its introduction, however, it is also possible that this was a consequence of a lean manufacturing intervention that took place at the same time. Variables affecting the intervention success were further explored though interviews with a sample of safety experts. This resulted in the development of a six stage model for successful safety culture intervention design and implementation. The insights gained from these studies were fed back to the industrial sponsor to contribute to corporate insight and understanding into variables impacting on employee safety culture and the design of successful safety improvement programs.

The retail business has been negatively affected due to the increasing customer concerns about food safety and the recent events related to microbiological and chemical contamination of food products, such as the melamine in infant formula and the multiple cases of produce pathogen contamination. It has been shown that a scientific-based food safety system, such as, Hazard Analysis and Critical Control Points (HACCP), help reduce the likelihood of food safety incidents. Nevertheless, companies with these kinds of systems have too experienced public food safety issues. Food safety professionals have created instruments to measure food safety based on lagging indicators, such as pathogen presence or food safety incident reduction. Though, they have not created metrics based on leading indicators to measure the behavior driven by the culture of employees who handle the food. The employees who handle food are influenced by cultural values and behave in a company based on the company's cultural influence; hence, food safety should also be measured in cultural terms as a leading indicator. In order to measure food safety culture of a retail company and understand differences among groups, the researcher used case study methodology to select a USA based retailer. The researcher described the culture of the retailer, as well as the leadership styles. Based on these descriptions, the food safety culture of the company and the employee constructs were defined and piloted for construct validity and construct reliability. Once validated, a food safety culture survey instrument was implemented in the operations area of this retailer. The results showed that the employees agreed or strongly agreed that food safety was part of the corporate culture. One of the factors influencing the food safety culture was service to the customer. The results showed that there were differences in food safety culture across the different groups, but with negligible or small effect size. One of the main contributions of this study was the development of a metric to measure food safety culture in the retail industry. It also suggests that besides food safety audit scores and incident reduction, food safety needs to be measured in terms of the corporate culture of the retailer. In an effort to improve food safety around the world, organizations should consider that culture plays an important role.

Developing a safety culture: The unintended consequence of a ‘one size fits all’ policy. Background Adverse events in maternity care are relatively common but often avoidable. Evidence suggests it is necessary to understand the safety culture of an organisation to make improvements to patient safety. The safety domains that are thought to influence safety culture in health care include: Safety Climate; Teamwork; Working Conditions; Perceptions of Management; Job Satisfaction; and Stress Recognition. Little is known about the safety culture in the Australian maternity setting, which was the impetus for this Study. This thesis reports an examination of the safety culture in a maternity service in New South Wales (NSW). Setting The Study took place in one maternity service located in two public hospitals in NSW, Australia. Concurrently, both hospitals were undergoing an organisational restructure. Design This mixed method research study used a concurrent triangulation design and included two Studies. The Policy Study explored the policy context in which the maternity service was situated; and, the Service Study examined the safety culture within the maternity service. Data collection included: • A policy audit and chronological mapping of the key policies influencing safety culture within the maternity service. • Safety culture surveys, the Safety Attitudes Questionnaire and Safety Climate Scale (59/210, 28% response rate) that measured the following six safety culture domains; Safety climate; Teamwork climate; Job Satisfaction; Perceptions of management; Stress recognition and Working conditions (Sexton et al., 2004). • Semi-structured interviews (15) with key maternity, clinical governance and policy stakeholders. Results The safety culture was found to be lacking across all six safety domains. The key finding was that the overarching policy context created unintended consequences for the maternity service and adversely influenced their capacity to have a positive safety culture. These unintended consequences reduced their available infrastructure and capacity to respond to adverse events; and created a lack of leadership at all levels to drive the safety and quality agenda. The safety culture was also influenced by inadequate communication during the escalation of care; inadequate supervision of junior medical staff; difficulty ensuring the right staffing and skill mix, and low staff morale. Conclusion The safety culture in this maternity setting was complex, context-specific but importantly, influenced by the broader policy context in which it was situated. This Study provides evidence that the policy context needs to be included as a seventh safety culture domain in health care. This Study has demonstrated the importance of policy on the capacity to ensure patient safety. Implications The policy context has not been previously identified as being important when addressing the safety culture in health care. Considering the influence of the policy context in relation to safety culture is an important step to develop strategies to improve patient safety in other settings. This is an area for future research.

Safety Management Systems (SMS) are becoming the industry standard for safety management throughout the aviation industry. As the Federal Aviation Administration (FAA) continues to mandate SMS for different segments, the assessment of an organization’s safety culture becomes more important. An SMS can facilitate the development of a strong aviation safety culture. This study describes basic principles and components of an SMS and how safety culture and SMS are integrated. Studies focusing on safety culture assessment were identified for other industries as well as for different areas of the aviation industry. The purpose of this study was to examine the relationship between an organization’s safety culture and SMS implementation in collegiate flight schools. The research study was designed to determine (a) relationship between SMS implementation and safety culture, (b) the relationship between safety promotion and safety culture, and (c) the relationship between management commitment and safety culture. The study population consisted of 453 individuals at 13 collegiate flight schools. Data were gathered through an online survey to safety officers at collegiate flight schools within the University Aviation Association to determine the level of SMS implementation; and the Collegiate Aviation Program Safety Culture Survey (CAPSCUS) was used to measure the safety culture at those collegiate flight schools. The results indicated that a relationship existed between SMS implementation and safety culture, safety promotion and safety culture, management commitment and safety culture. The relationship for all three was more prominent within the Formal Safety Program major scale of the CAPSCUS. It is recommended that collegiate flight schools examine their existing level of SMS, management commitment, and their safety promotion and assess safety culture within their institution. Future studies should be done to further examine the relationship between SMS implementation and safety culture so that the collegiate flight training environment would have guidance regarding SMS implementation.

A positive safety culture has been shown to contribute to a firm's ability to avoid or reduce the occurrence of occupational accidents and injuries. In American workplaces alone 3,582 people died and 5.1 million people were disabled in 2009 and the cost to corporate America was $169 billion and an additional productivity loss of 95 million work days. The economic cost to each American household is about $1,200. Firms that establish and maintain a positive safety culture are able to achieve a competitive advantage in the market. While much research exists showing the relationship between safety culture and accident reduction, less guidance is found on how companies might achieve such improvement through cultural change. Attempts have been made to determine the factor structure of safety culture, that is, the identification of the antecedents of a positive safety culture. However, to date no general consensus has emerged among researchers about the exact elements of the factor structure. Research methodologies have been blamed for biasing the research results and thereby causing the lack of consensus. This dissertation uses a different methodology, the Delphi method combined with Hofstede's well-known onion model of organizational culture, to determine those organizational practices that lead to a positive safety culture. Delphi is a mixed methodology that begins with an exploratory approach followed by the more traditional quantitative method. The exploratory front-end was deemed appropriate given that prior traditional survey instruments most likely introduced researcher bias through a myopic view of safety culture. Delphi also differs by utilizing purposeful sampling versus random sampling which provides a high level of expertise to inform the research. After four rounds of inquiry with a panel of experts, a consensus was reached on 18 organizational practices that lead to a positive safety culture. This research adds to the understanding of safety culture, provides useful information for both practitioners and academic researchers, and offers launch points for extensions of the research.

Poster campaigns have been studied before but never in relation to perceived safety culture. Virtual reality was used to study how safety signage, or lack thereof, affects peoples’ perception of a company’s priority of safety, safety awareness, safety culture, and their own perception of how safe they feel or think a coworker would feel in the environment. There were four virtual scenes used – No Signage, Safety Signs, Safety Posters, and Safety Posters + Safety Signs. The four environments were similar regarding objects, colors, and size; however, the signage on the walls differed in each. Statistical significance was found for each of the five dependent variables tested. Participants scored the scenes using a ten-question survey given after seeing each environment. The results confirm the original hypothesis that safety posters increase the perceived safety culture in an industrial site environment, compared to no signage or only safety signs.

Patient safety experts identify changes in culture as critical to creating safer care (Flin, 2007; Leape, 1994; Reason, 1997; Vincent, Taylor-Adams & Stanhope, 1998). Yet there is limited understanding of how to best study, evaluate and make changes to patient safety culture. The literature on organizational culture, safety sciences and health services research suggests varying perspectives on studying culture and an evolving approach to creating tools to measure culture change. This thesis reports two projects. The first project used the Manchester Patient Safety Culture Assessment Tool, the Modified Stanford Instrument, and qualitative interviews to examine whether safety culture profiles varied by research method and instrument used to assess culture. Comparative assessment of the results suggests that while the quantitative measurement tools provide a high level organizational summary of safety issues, the qualitative interviews provide a more fine-grained understanding of the contextual and local features of the culture. The second research project used a multiple case study design to understand what hospitals have learned from trying to improve patient safety culture. Interviews in three organizations were used to determine how these organizations shifted their cultures. Although each organization had different experiences and used varying methods, they all created culture change through the simultaneous implementation of practice, policies and strategic framing of patient safety culture concepts in their everyday work. The third research paper examined how leaders measured changes in patient safety culture. Both leaders and front line workers look to both process measures (e.g., talking about safety and encouraging patient safety activities) together with outcome measures (e.g., adverse events, infection rates, and culture survey results) to evaluate their success in culture change. Overall this dissertation deepens our knowledge of how methods influence our assessment of patient safety culture and how leaders influence culture change. Future research needs to assess in more detail the roles of leaders and middle managers to understand how these individuals are able to reconcile the practice environment challenges while continuing to create a culture of patient safety.

Patient safety experts identify changes in culture as critical to creating safer care (Flin, 2007; Leape, 1994; Reason, 1997; Vincent, Taylor-Adams & Stanhope, 1998). Yet there is limited understanding of how to best study, evaluate and make changes to patient safety culture. The literature on organizational culture, safety sciences and health services research suggests varying perspectives on studying culture and an evolving approach to creating tools to measure culture change. This thesis reports two projects. The first project used the Manchester Patient Safety Culture Assessment Tool, the Modified Stanford Instrument, and qualitative interviews to examine whether safety culture profiles varied by research method and instrument used to assess culture. Comparative assessment of the results suggests that while the quantitative measurement tools provide a high level organizational summary of safety issues, the qualitative interviews provide a more fine-grained understanding of the contextual and local features of the culture. The second research project used a multiple case study design to understand what hospitals have learned from trying to improve patient safety culture. Interviews in three organizations were used to determine how these organizations shifted their cultures. Although each organization had different experiences and used varying methods, they all created culture change through the simultaneous implementation of practice, policies and strategic framing of patient safety culture concepts in their everyday work. The third research paper examined how leaders measured changes in patient safety culture. Both leaders and front line workers look to both process measures (e.g., talking about safety and encouraging patient safety activities) together with outcome measures (e.g., adverse events, infection rates, and culture survey results) to evaluate their success in culture change. Overall this dissertation deepens our knowledge of how methods influence our assessment of patient safety culture and how leaders influence culture change. Future research needs to assess in more detail the roles of leaders and middle managers to understand how these individuals are able to reconcile the practice environment challenges while continuing to create a culture of patient safety.

Objective: To examine the perception of patient safety culture amongst health care workers in Libyan Hospitals. Study Design: The study adopted a mixed methods approach with 2 phases. Phase 1 was conducted prior to the Libyan revolution. This was a quantitative research study, which used the Survey of Hospital Patient Safety Culture (HSOPSC) that was developed by the US Agency for Health Care Research and Quality (AHRQ, 2004). Phase 2 was conducted post revolution and it was a qualitative research study, which used semi-structured interviews. Setting: The three largest hospitals which were located in the Northeast of Libya were involved in the study. Participants and sampling: Phase 1 of the study included a stratified sample of 346 health care workers who were working as Doctors, Nurses, Technicians, Pharmacists and Managers. Phase 2 of the study used a purposeful sample which involved 27 health care workers from those took part in the survey study. Main Outcome Measures: The survey measured twelve Patient Safety Culture dimensions. It indicated that ten of the twelve dimensions were weak and need to be improved. The interview findings also showed that the 12 patient safety culture dimensions were very weak and shed light on some of the reasons for this sub-optimal practice. Findings: The respondents who took part in the study were from different departments in the three hospitals. The survey showed the dimensions with acceptable positive ratings were teamwork within hospitals and organizational learning and continuous improvement, while those with lowest ratings included frequency of reporting errors, non-punitive response to error and communication and openness. Approximately 60% of health care workers perceived patient safety culture practice in Libya negatively. Twenty respondents (5.8%) who gave an excellent grade for patient safety in their hospitals. Furthermore, the interviews results revealed that patient safety culture dimensions were very weak. The interview explored further factors and issues of poor safety culture in the 3 hospitals; which had not been identified in the survey. These were related to results of the political changes, administrative factors, environmental issues, organisational system issues, and health care workers matters. Conclusions: The study identified that the current state of patient safety culture in Libyan hospitals is very weak and there is a need for improvement to safety practice and for promotion of this important issue amongst those health care workers and health managers working at the frontline of health care delivery. Furthermore, the study found that the level of patient safety in the 3 hospitals was below an unacceptable level according to the perceptions of the health care staff. It was noted that there was no effective patient safety system in any of the 3 hospitals to deal with patient safety issues and there were no proactive patient safety measures in place to reduce the level of risk to patients. Furthermore, the study revealed other significant aspects that represent a serious threat to patient safety in the 3 hospitals, which were mainly due to poor hospital management, ineffective emergency services and a lack of training programmes. Moreover, poor organisation of monitoring systems for the licensing of medical practice of health care workers was shown to have a significant impact on patient safety culture. Lastly, the study showed the political change in Libya had affected patients’ safety sharply as result of the military conflict and the lack of hospitals’ preparedness to cope with such emergency events.