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Just Culture as a Foundation for Joy in Work: The Impact of Leaders

Posted By Administration, Thursday, March 2, 2017
Updated: Thursday, March 2, 2017

What can health care leaders do to help reduce burnout among their colleagues?

by Barbara Balik, EdD, MS, RN


Burnout and lack of joy in work pose significant risks to health care organizations: 54% of US physicians are burned out and 33% of new nurses seek another job within one year. Burnout is a syndrome characterized by exhaustion, cynicism or depersonalization, and a sense of loss of personal effectiveness. This problem takes a personal toll on health care team members and also seriously impacts patient safety. The correlation between greater engagement and safer patient care is well documented. Reducing burnout results in improved quality, safety, and efficiency with lower turnover rates.

Joy in work occurs when all team members,

no matter their role, find meaning and

purpose in what they do.


Abundant evidence points to leadership behaviors that are an antidote to this significant problem. What leaders do makes a difference in reduced burnout, enhanced teamwork, lower turnover and safer care. 


Health care leaders can reduce burnout and achieve safer care by focusing on selected cultural essentials. Through the same leadership actions, they can get a two-for-one outcome: just culture and joy in work. Leaders who ensure just culture behaviors will nurture environments for both safe care and enable colleagues to find joy and meaning in work. 


Steps for leaders to integrate just culture and joy in work include:

  • Definitions of what are they are so everyone has a common understanding
  • Clear purpose statements of why they are important, which offers a clear focus
  • Actions that describe how we make gains in both



Just culture: a learning environment based on respect, trust, and fairness to achieve safe, highly reliable care.


It is an environment where:

  • Consistent clarity exists between human error in unreliable systems and intentionally unsafe acts.
  • Reporting and learning from system flaws and mistakes are the norm and are valued.
  • Safety science is used to understand human fallibility with systems designed to mitigate that fallibility.
  • Response to harm is not based on patient outcome.
  • There is confidence that it is safe to report and learn from mistakes.
  • Accountability is clear for all roles. (See Pichert et al. 2013.)

 In short, team members will know they will be treated respectfully, consistent with organizational values.


Joy in work: when all team members, no matter their role, find meaning and purpose in what they do. It results when colleagues have an intellectual, behavioral, and emotional connection to the organization’s mission (IHI in press). These environments are characterized by psychological safety. Psychological safety means an environment where all team members feel secure and capable of changing; they experience respectful interactions among all; are able to ask questions, seek feedback, admit mistakes, and propose ideas (Edmondson 2012).



The primary way leaders embed culture is what they pay attention to and how they react to critical incidents (Schein 2004). Leaders are responsible for paying attention to and developing organizational behaviors that promote psychological safety, which enables both engagement and safety.


For instance, of seven drivers of team engagement identified, three are greatly enhanced by psychological safety (Edmondson 2012):

  • Organizational culture and values are evidenced in the behaviors that are consistent with a just and fair environment. How leaders react to critical incidents involving patient harm is a key behavior that reflects consistency –or lack of– with the intended organizational culture and values.
  • Social support and community at work are illustrated by respectful interactions among all team members no matter their role. Members feel they can speak up without fear of retribution; are supported by colleagues and leaders to do their best; and experience a sense of camaraderie in their daily work. 
  • Workload and job demands show a balance between the work to be done and the time/resources available. Excessive workload is frequently due to ineffective systems that waste time, energy, and good will. These same ineffective systems lead to unsafe conditions.


As part of a well-designed leadership development process, leaders can ask the following organizational assessment questions to further advance their outcomes in safety and joy in work.

  • How well do we demonstrate just culture principles in every part of the organization? 
  • What happens when an error occurs?  What are leaders’ responses? Do the responses vary depending on level of harm or by what role was involved?
  • Are we as focused on much on system failures as we are on harm events?
  • Do we act daily to show that respecting others and treating them fairly is essential?
  • What fairness gaps do we have in our current actions?
  • Do we promote psychological safety through the following:

o   Be accessible, visible and approachable to develop relationships with team members.

o   Acknowledge the limits of current knowledge; frame the work as highly complex requiring all to contribute for great outcomes.

o   Be willing to show fallibility and humility; acknowledge that we do not have all the answers and are learning.

o   Invite participation.

o   View failures as learning opportunities.

o   Use direct, clear language.

o   Set boundaries about what is acceptable behavior and hold others accountable for boundary violation (Edmondson 2012).


This list of what, why, and how is a means of strengthening the leadership journey towards safer care and an environment where joy and meaning thrive.


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Do you find joy and meaning in your work? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.



Edmondson, A. 2012. Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy. San Francisco: Jossey-Bass.

Institute for Healthcare Improvement. 2017. Joy in Work White Paper. In press.


Schien E. 2004. Organizational Culture, 3rd Ed. San Francisco: Jossey-Bass



Barbara Balik, EdD, MS, RN, is co-founder of Aefina Partners and a longtime member of the NPSF Board of Advisors.

Tags:  burnout  culture  workforce safety 

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Addressing Workplace Violence in Health Care

Posted By Administration, Tuesday, December 13, 2016

What can health care staff and leaders do to help prevent violence and mitigate the impact?
The Joint Commission has some ideas.

by Ann Scott Blouin, PhD, RN, FACHE


Caring for patients and for each other today unfortunately must also include understanding the potential harm to patients and staff safety associated with the sad reality of violence in our workplaces.

Many of us in health care have witnessed or experienced workplace violence firsthand. Workers in health care are five times more likely to be victims of nonfatal assaults or violent acts than the average worker in all other occupations, according to the Bureau of Labor Statistics. It is critical, therefore, for those in the health care community to receive key resources to help them prepare for and address, as well as hopefully prevent, violent situations from taking place.

The Joint Commission recently introduced
a virtual workforce violence resource center
to help health care organizations deal with
this very important problem.

Health care staff come to their employment settings each shift expecting to help patients. Few physicians, nurses, or other health professionals would anticipate having to deal with the increasing episodes of violence spilling over from our communities into our hospitals, ambulatory centers, and other health care locations. Indeed these incidences can hurt or kill patients, staff, and visitors. “Active shooter” situations have become another important component of emergency management preparedness.


What can health care staff and leaders do to help prevent violence and mitigate the impact? One thing is to seek out education about the issue and potential solutions. The Joint Commission recently introduced a virtual Workforce Violence Resource Center to help health care organizations deal with this very important problem. This portal, which is free and open to all, contains links to articles and research, “From the Field” case studies, and links to federal and state agencies that address workplace violence.

The American Hospital Association has also announced resources available through its Hospitals Against Violence initiative.


The high reliability concept of "mindfulness” is an apt description of the vigilance needed to notice anything unusual or something that just "feels wrong” as you go about patient care. That intuition, coupled with education on how to de-escalate crisis situations and limit damage, can save lives.

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Does your organization have formal plans for addressing or preventing workplace violence? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.


Ann Scott Blouin, PhD, RN, FACHE, is executive vice president, Customer Relations, at The Joint Commission. She serves on the National Patient Safety Foundation's Board of Directors and is a lifetime member of the American Society of Professionals in Patient Safety at NPSF. Contact her at

Tags:  workforce safety  workforce violence 

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Workplace Violence in Health Care

Posted By Administration, Tuesday, April 19, 2016
Updated: Monday, April 18, 2016

The healing professions are at greater risk of experiencing violence in the workplace than most professions,
but many are working to reduce the risk.

by Patricia McTiernan, MS

Ann Scott Blouin
Ann Scott Blouin, PhD, RN, FACHE,
will discuss workplace violence and
methods of de-escalating it at the
NPSF Patient Safety Congress.


In March of this year, a patient shot and killed a urologist in New Orleans, then turned the gun on himself. The incident was shockingly reminiscent of last year’s killing of a surgeon at a hospital in Boston by a distraught family member.


Although the murder of health care professionals is an extreme form of violence that is relatively rare, overall, health care professionals are at far greater risk than others of experiencing violence in the workplace. According to the Occupational Safety and Health Administration (OSHA), in the decade between 2002 and 2013, the rate of violent incidents requiring time off for the worker to recover was more than 4 times greater in health care than in other industries. OSHA data show that there are almost as many serious violent injuries in health care settings as there are in all other workplaces combined.


What do we know about the why of all this? Ann Scott Blouin, PhD, RN, FACHE, executive vice president, Customer Relations, at The Joint Commission (TJC), says part of it has to do with how open and accessible health care settings are, as well as the emotional state that patients and family members may be in while at a health facility.


“There are lots of entry points, making security more challenging. Also patients and family members in a health care setting often have reasons to be upset or concerned,” says Dr. Blouin. “Often health care providers need to have difficult conversations with patients and their families.”


Another factor is the incidence of patients having not only medical and surgical conditions, but also underlying mental illness, which can contribute to the risk of violence. And if patients, visitors, or family members typically live in an environment characterized by violence, they may bring that perspective and sometimes weapons into the health care setting, says Dr. Blouin.


If there is a bright spot, it is that many organizations now recognize this risk and are taking steps to educate the workforce and make health care safer for those on the front line of care.


The Joint Commission published a monograph in 2012 on the topic of workforce safety in health care and later this year plans to launch a web portal available to all with resources and tools. Among the resources will be the American Society for Healthcare Risk Management’s Workplace Violence Risk Assessment Tool.


In 2013, the National Patient Safety Foundation’s Lucian Leape Institute issued a report calling workforce safety a precondition to patient safety; Joint Commission fully supports that perspective and has published Sentinel Event Alerts and Quick Safety Alerts around the topics of escalating workplace violence.


If she could share only one piece of wisdom about this issue, Dr. Blouin says, “Don’t take your patients’ or your own personal safety for granted.” She points out that there are proven tactics to de-escalate a potentially violent situation, and that anyone can learn them.


“For those working in behavioral health, a standard part of the curriculum is to learn de-escalation techniques and be able to help people move from being angry and upset to a calmer state. Anyone regardless of their education and experience, whether a nurse, a physician, an environmental service worker, or a security officer, can benefit by learning these techniques,” she says.

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Ann Scott Blouin will be speaking on the topic of workplace violence and tactics to counteract it during Breakout Session 301 at the NPSF Patient Safety Congress, May 24, in Scottsdale. Find out more about her session and the full program at


Comment on this post below. Note: to post a comment you must be logged in. Register or log in.

Patricia McTiernan, MS is assistant vice president for communications at the National Patient Safety Foundation and editor of the P.S. Blog. Contact her at

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Tags:  2016 NPSF Congress  workforce safety 

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