Medicine Studies

, Volume 2, Issue 4, pp 265–278 | Cite as

Promoting a Safety Culture in Health Care. Presenting a Relational-Interpretive Perspective



This paper analyses various approaches to the concept of a ‘safety culture’ in terms of their epistemological assumptions regarding the nature of learning. As a result of this analysis, the study proposes a relational-interpretive framework for the promotion of safety in health care, which is based on relational theories and the philosophy of conceptual pragmatism as this can be used to integrate the various strands of current safety research. In particular, the approach based on a relational-interpretive perspective can bridge the apparent dualist gap that exists between the rational objectivist perspective and the relativist perspective on the role of learning in developing a safety culture. According to the relational-interpretive perspective of safety management that is proposed here, organizational members need to give continuous attention to the accepted organizational norms and values, which shape the safety culture. A case study from a health care safety project in Sweden is utilized to illustrate the ideas advanced in this paper.


Safety culture Health care Learning Objectivism Relativism Pragmatism Relational theory Relational-interpretive perspective Deviant reporting systems Error reporting systems Incident reporting systems Case study 


  1. Alvesson, M. 1996. Communication, power and organization, vol. 72. Berlin: Walter de Gruyter.Google Scholar
  2. Amalberti, R. 2001. The paradoxes of almost totally safe transportation systems. Safety Science 37: 109–126.CrossRefGoogle Scholar
  3. Archer, M. 1988. Culture and agency. Cambridge: Cambridge University Press.Google Scholar
  4. Archer, M. 1995. Realist social theory: The morphogenetic approach. Cambridge: Cambridge University Press.CrossRefGoogle Scholar
  5. Bakhtin, M.M. 1986. Speech genres and other late essays (trans: McGee, Vern W.). Austin, TX: University of Texas Press.Google Scholar
  6. Barley, S.R., and G. Kunda. 1992. Design and devotion: Surges of rational and normative ideologies of control in managerial discourse. Administrative Science Quarterly 37(3): 363–399.CrossRefGoogle Scholar
  7. Berger, H., and T. Luckmann. 1966. The social construction of reality. NY: Anchor.Google Scholar
  8. Bhaskar, R. 1989. Reclaiming reality a critical approach to contemporary philosophy. London: Verso.Google Scholar
  9. Cheyne, A., S. Cox, A. Oliver, and J.M. Tomás. 1998. Modelling safety climate in the prediction of levels of safety activity. Work & Stress 12(3): 255–271.CrossRefGoogle Scholar
  10. Cooper, M.D. 2000. Toward a model of safety culture. Safety Science 36(2): 111–136.CrossRefGoogle Scholar
  11. Cox, S., and R. Flin. 1998. Safety culture: Philosopher’s stone or man of straw? Work & Stress 12(3): 189–201.CrossRefGoogle Scholar
  12. Creed, W.E.D., S.K. Stout, and K.H. Roberts. 1993. Organizational effectiveness as a theoretical foundation for research on reliability-enhancing organizations. In New challenges to understanding organizations, ed. K.H. Roberts, 55–73. New York: Maxwell Macmillan International.Google Scholar
  13. Cunliffe, A. 2002a. Reflexive dialogical practice in management learning. Management Learning 33(1): 35–61.CrossRefGoogle Scholar
  14. Cunliffe, A. 2002b. Social poetics as management inquiry: A dialogical approach. Journal of Management Inquiry 11(2): 128–146.Google Scholar
  15. Dean, B., M. Schachter, C. Vincent, and N. Barber. 2002. Prescribing errors in hospital inpatients: Their incidence and clinical significance. Quality and Safety in Health Care 11: 340–344.CrossRefGoogle Scholar
  16. Donchin, Y., D. Gopher, M. Olin, Y. Badihi, M. Biesky, C.L. Sprung, et al. 2003. A look into the nature and causes of human errors in the intensive care unit. Quality and Safety in Health Care 12(2): 143–148.CrossRefGoogle Scholar
  17. Elkjær, B. 1999. In search of a social learning theory. In Organizational learning and the learning organization. Developments in theory and practice, ed. M. Easterby-Smith, L. Araujo, and J. Burgoyne, 75–91. London: Sage.Google Scholar
  18. Fishman, D.B. 1999. The case for pragmatic psychology. New York: New York University Press.Google Scholar
  19. Gergen, K. 2007. An invitation to social construction. London: SAGE.Google Scholar
  20. Giddens, A. 1987. Social theory and modern sociology. Cambridge: Polity.Google Scholar
  21. Giroux, H., and S. Landry. 1998. Schools of thought in and against total quality. Journal of Managerial Issues 10(2): 183–203.Google Scholar
  22. Hudson, P. 1999. Safety culture—the way ahead? Theory and practical principles. In Profiting through safety: Proceedings of the international aviation safety management conference, ed. L. Hartley, E. Derricks, S. Nathan, and D. McLeod, 93–102. Perth, Australia: IASMC.Google Scholar
  23. International Atomic Energy Agency. 1991. Safety culture. Vienna: International Nuclear Safety Advisory Group.Google Scholar
  24. International Atomic Energy Agency. 1992. The chernobyl accident: Updating of INSAG-1. Vienna: International Nuclear Safety Advisory Group.Google Scholar
  25. La Porte, T.A., and D.S. Metlay. 1996. Hazards and institutional trustworthiness: Facing a deficit of trust. Public Administration Review 56(4): 341–347.CrossRefGoogle Scholar
  26. Lave, J. 1993. The practice of learning. In Understanding practice: Perspectives on activity and context, ed. S. Chaiklin and J. Lave, 3–32. Cambridge, UK: Cambridge University Press.CrossRefGoogle Scholar
  27. Lave, J., and E. Wenger. 1991. Situated learning: Legitimate peripheral participation. Cambridge: Cambridge University Press.Google Scholar
  28. Lewis, C.I. 1929. Mind and the world-order: Outline of a theory of knowledge. New York: Charles Scribner’s Sons.Google Scholar
  29. Manser, T., and T. Wehner. 2002. Analysing action sequences: Variations in action density in the administration of anaesthesia. Cognition, Technology & Work 4: 71–81.CrossRefGoogle Scholar
  30. Mauléon, C. 2009. ‘Getting’ it together in joint directed action. PhD thesis, Chalmers University of Technology. see
  31. Mauléon, C., and B. Bergman. 2009. Exploring the epistemological origins of Shewhart’s and Deming’s theory of quality: Influences from C.I. Lewis’ conceptualistic pragmatism. International Journal of Quality and Service Sciences 4(1):77–89. Google Scholar
  32. Mearns, K., and R. Flin. 1999. Assessing the state of organizational safety—culture or climate? Current Psychology 18(1): 5–18.CrossRefGoogle Scholar
  33. Park Daahlgard, S. M. 2000. From ancient philosophies to TQM and modern management theories. (Licentiate thesis) Linköping University Press, Linköping.Google Scholar
  34. Perrow, C. 1984. Normal accidents: Living with high-risk technologies. New-York, USA: Basic Books, Inc.Google Scholar
  35. Reason, J.T. 1997. Managing the risks of organizational accidents. Aldershot, UK: Ashgate Publishing Limited.Google Scholar
  36. Reason, J.T. 1998. Achieving a safe culture: Theory and practice. Work & Stress 12(3): 293–306.CrossRefGoogle Scholar
  37. Reason, J.T. 2000. Human error: Models and management. British Medical Journal 320: 768–770.Google Scholar
  38. Roberts, K., and R. Bea. 2001. When systems fail. Organizational Dynamics 29(3): 1779–1791.CrossRefGoogle Scholar
  39. Rochlin, G.I. 1993. Defining “high reliability” organizations in practice: A taxonomic prologue. In New challenges to understanding organizations, ed. K.H. Roberts, 11–32. New York: Maxwell Macmillan International.Google Scholar
  40. Rochlin, G.I. 1999. Safe operation as a social construct. Ergonomics 42(11): 1549–1560.CrossRefGoogle Scholar
  41. Schon, D.A. 1983. The reflective practitioner: How professionals think in action. NY: Basic Books.Google Scholar
  42. Shotter, J. 2002. Conversational realities: Constructing life through language. London: SAGE.Google Scholar
  43. Shotter, J. 2005. Inside the moment of managing: Wittgenstein and the everyday dynamics of our expressive-responsive activites. Organisation Studies 26(1): 113–135.Google Scholar
  44. Shotter, J. 2008. Dialogism and polyphony in organizing theorizing in organization studies: Action guiding anticipations and the continuous creation of novelty. Organization Studies 29(4): 501–524.CrossRefGoogle Scholar
  45. Singer, S.J., D.M. Gaba, J.J. Geppert, A.D. Sinaiko, S.K. Howard, and K.C. Park. 2003. The culture of safety: Results of an organization-wide survey in 15 California hospital. Quality and Safety in Health Care 12(2): 112–118.CrossRefGoogle Scholar
  46. Snook, S.A. 2000. Friendly fire: The accidental shootdown of US Black Hawks over Northern Iraq. Princeton, NJ: Princeton University.Google Scholar
  47. Styhre, A., S. Ollila, J. Roth, D. Williamson and L. Berg. 2008. Heedful interrelating, knowledge sharing and new drug development. Journal of Knowledge Management 12(3).Google Scholar
  48. Sztompka, P. 1991. Society in action—the theory of social becoming. London: The University of Chicago Press.Google Scholar
  49. Tufte, E.R. 1997. Visual explanations. Cheshire, CT: Graphic Press.Google Scholar
  50. Vaughan, D. 1996. The challenger launch decision: Risky technology, culture, and deviance at NASA. Chicago, IL: The University of Chicago Press.Google Scholar
  51. Vygotsky, L.S. 1986. Thought and language. Translation newly revised by Alex Kozulin. Cambridge: MIT Press.Google Scholar
  52. Weick, K.E. 1987. Organizational culture as a source of high reliability. California Management Review 29(2): 112–127.Google Scholar
  53. Weick, K. 1995. Sensemaking in Organizations. Thousand Oaks: SAGE.Google Scholar
  54. Weick, K., and K. Roberts. 1993. Collective mind in organizations: Heedful interrelating on flight decks. Administrative Science Quarterly 38(3): 357–381.CrossRefGoogle Scholar
  55. Weick, K., and K.M. Sutcliffe. 2003. Hospitals as cultures of entrapment: A re-analysis of the Bristol Royal infirmary. California Management Review 45(2): 73–84.Google Scholar
  56. Weick, K., and K. Sutcliffe. 2007. Managing the unexpected. US: Jossey-Bass.Google Scholar
  57. Weick, K., M. Sutcliffe, and D. Obstfeld. 2008. Organizing for high reliability: Processes of collective mindfulness. In Crisis management, ed. A. Boin. SAGE: London.Google Scholar

Copyright information

© Springer Science+Business Media B.V. 2011

Authors and Affiliations

  1. 1.Human and Organisation PerformanceArevaParisFrance
  2. 2.Department of Business Administration and Gothenburg Research Institute Gothenburg University, School of Business Economics and LawGothenburgSweden

Personalised recommendations