Keeping patients safe in healthcare organizations: a structuration theory of safety culture

J Adv Nurs. 2011 Aug;67(8):1846-55. doi: 10.1111/j.1365-2648.2011.05619.x. Epub 2011 Apr 7.


Aim: This paper presents a discussion of the use of structuration theory to facilitate understanding and improvement of safety culture in healthcare organizations.

Background: Patient safety in healthcare organizations is an important problem worldwide. Safety culture has been proposed as a means to keep patients safe. However, lack of appropriate theory limits understanding and improvement of safety culture.

Data sources: The proposed structuration theory of safety culture was based on a critique of available English-language literature, resulting in literature published from 1983 to mid-2009. CINAHL, Communication and Mass Media Complete, ABI/Inform and Google Scholar databases were searched using the following terms: nursing, safety, organizational culture and safety culture.

Discussion: When viewed through the lens of structuration theory, safety culture is a system involving both individual actions and organizational structures. Healthcare organization members, particularly nurses, share these values through communication and enact them in practice, (re)producing an organizational safety culture system that reciprocally constrains and enables the actions of the members in terms of patient safety. This structurational viewpoint illuminates multiple opportunities for safety culture improvement.

Implications for nursing: Nurse leaders should be cognizant of competing value-based culture systems in the organization and attend to nursing agency and all forms of communication when attempting to create or strengthen a safety culture.

Conclusion: Applying structuration theory to the concept of safety culture reveals a dynamic system of individual action and organizational structure constraining and enabling safety practice. Nurses are central to the (re)production of this safety culture system.

MeSH terms

  • Communication
  • Health Facility Administration*
  • Health Knowledge, Attitudes, Practice
  • Hospitals / standards
  • Hospitals / statistics & numerical data
  • Humans
  • Leadership
  • Medical Errors / mortality
  • Medical Errors / prevention & control
  • Models, Organizational*
  • Nursing Staff / organization & administration
  • Organizational Culture
  • Patients
  • Safety Management / organization & administration*
  • Safety Management / standards
  • United States / epidemiology