What kind of workplace culture do we want?

Welcome to our guest blog. This month’s blog is from Dame Professor Donna Kinnair, Director of Nursing Policy and Practice at the Royal College of Nursing and a Patron of AvMA. Donna is expressing her personal view here, and we are very interested in knowing what others think on the subject.

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Dame Professor Donna Kinnair

What kind of workplace culture do we want?

By Dame Professor Donna Kinnair, Director of Nursing Policy and Practice at the Royal College of Nursing


We all face daily challenges in doing the things we need to do. These challenges often involve a lack resources of some kind. We often find ourselves up against a deadline, missing important information or short of manpower to get jobs done.

We often meet these challenges by adapting to the circumstances in some way. We reprioritise our “to do” lists, we divide up work or delegate it in different ways. We are continually balancing demands and resources.

This balancing act has a name – the ETTO principle – which stands for efficiency thoroughness trade-off. This was described by safety expert Erik Hollnagel. Simply put it means that individuals and organisations cannot be efficient and thorough at the same time. There is always a trade-off between the two.

When circumstances demand a high level of productivity thoroughness is reduced until that goal is met. Conversely if an important safety goal is prioritised, efficiency is reduced until the safety goal is met.

The solution is not to be thorough at all times. This is not an option for a hospital, for example, that must be open for emergency cases and maintain the turnover of elective procedures. Neither is it possible to be efficient at all times as this would jeopardise timely operations quickly too.

Nurses face that dilemma at work every day. Workflow problems are commonplace. Nurses develop skills to respond to situations at hand when information, services or supplies are not provided as expected.

Nursing also requires high level reasoning and decision making: co-ordinating tests and therapies and interpreting data to recognise patterns that are precursors to deterioration in patients and intervening when necessary are examples of these skills.

Nurses provide direct care to multiple patients so they must continually monitor and prioritise work according to competing needs. Healthcare can be unpredictable. Services are delivered by a range of different people. Success or failure requires a high level of interdependence between people in a dynamic environment.

Why then do hospitals and health services generally find learning a challenge? Culture and organisational design are a strong influence. Three factors are worth mentioning, particularly since each one would seem to benefit nurses and patients (Tucker and Edmonson 2003). Individual vigilance and problem solving is highly valued and promoted. Short term solutions, while personally satisfying, may create other issues “downstream”. Second staffing models leave nurses with little option but to patch issues in order to get work done. Underlying causes that result in rework and unnecessary steps can remain untouched. Finally worker empowerment may mean the absence of managerial support particularly when issues need resolving that involve other teams and the capacity to use a system-wide perspective.

Each factor would seem to promote efficiency but actually undermines it. The consequences of hardwiring efficiency at the expense of thoroughness into organisational design are far reaching. The staff dealing with these issues grow steadily frustrated with processes they consider worthless. Groups remain isolated. When needs and concerns go unheard fear and blame can prevail.

The most common culture in healthcare settings is what Dekker calls a “retributive just culture”. He writes that this culture asks these questions:

  • Which rule is broken?
  • Who did it?
  • How bad was the breach, and what should the consequences be?
  • Who gets to decide this?

Many types of organisations seem to prefer retributive just cultures. Perhaps this is also a display of collective ETTO behaviour. They want to know who is responsible. Scapegoating is far easier than looking for genuine lessons that would involve a change to the status quo.

Dekker describes an alternative to this. A “restorative just culture” asks a different set of questions:

  • Who is hurt?
  • What do they need?
  • Whose obligation is it to meet that need?
  • How do you involve the community in this conversation?

A restorative just culture asks what is responsible. The focus is on the things that created the conditions that led up to the incident. But it would also be concerned with the needs of those involved. So, in the same way that people cannot be efficient and thorough at the same time, we cannot have scapegoats and safer systems (Shorrock 2017).

A better way of working is to look at places where thoroughness should be given priority over efficiency. Typically this happens in transitions between services and functions e.g. handovers, discharges etc. Such “hot spots” are critical to productivity and safety. The key then is to design transitions in such a way as to help people to do “the right thing” and make it hard to do “the wrong thing”.

Fortunately health and social care is increasingly aware of a science that can support this. The purpose of Human factors as a discipline is to provide “methods and approaches which address known issues of team work, integration, impact sustainability of change” (CIEHF 2017). Health and social care needs a culture that embraces a restorative justice approach and a safety management system founded on a Human Factors approach to the services it provides.


Hollnagel, E (2009). The ETTO principle: Efficiency-thoroughness trade-off. Why things that go right sometimes go wrong. Ashgate.

Tucker, AL and Edmonson A.C. (2003). Why hospitals don’t learn from failures: organizational and psychological dynamics that inhibit system change. California Management Review. Vol 45. No.2 pp 55-72.

Dekker, S (2016). Just Culture: Restoring trust and accountability in your organization. Third Edition. CRC Press.

Shorrock S (2017). Just culture in LaLa land. Blog post.

Chartered Institute of Ergonomics and Human Factors (in press). Human factors (ergonomics) in health and social care. CIEHF.