The challenge of creating a safety culture in the NHS: could better understanding of the links between risk perception and behaviour help?

This doctoral study of NHS staff in an acute hospital sought to increase understanding of how people identify and respond to threats in their environment through investigating the elusive links between perceptions of risk,... [ view full abstract ]

This doctoral study of NHS staff in an acute hospital sought to increase understanding of how people identify and respond to threats in their environment through investigating the elusive links between perceptions of risk, selection and decision making, and response behaviour.

The research used qualitative methods, including semi-structured interviews, observation, and examination of documentary evidence. Phase 1 involved observation on wards, and interviews asking ward based clinical staff about their working day. Participants interviewed in Phase 2 were clinical and managerial personnel reporting a potential risk to patient safety attributed to shortage of staff.

Data analysis used a novel approach in which all behaviour is conceived as a response to perceived risk and focusing, not on what motivates behaviour, but on what potential outcomes are being avoided. Thus analysis of people's responses to multiple threats concentrates on what options for action are rejected and why, and how the severity and imminence of the risk that each threat poses is determined.

Results revealed that staff were aware of multiple threats in their working environment, simultaneously posing risks to themselves, to other staff and to patients. The data suggested that staff utilised two levels of decision-making in order to carry out their tasks. The first was to select (consciously or unconsciously) the threat appearing to offer the greatest risk and requiring the most urgent response. Staff were frequently aware of this prioritising process, and commented on the difficulty of choosing between competing needs. Only when the focal risk had been identified was the second level of decision-making utilised to select possible responses. Both levels of decision-making were influenced to a greater or lesser degree by both cognitive and emotional processes, and the same threat might be responded to differently by different people, or by the same person under different circumstances.

Although in theory patient safety and the delivery of good quality care was considered by respondents to be of the highest importance, in practice, faced with multiple threats, staff did not always feel able to prioritise threats to patients. The current policy emphasis on creating a safety culture in the NHS might usefully consider how to diminish the number of threats staff perceive in their environment, thus allowing them to focus more exclusively on the needs of patients.