cultural humility and hospital safety

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Journal of Clinical Psychology inMedical Settings ISSN 1068-9583 J Clin Psychol Med SettingsDOI 10.1007/s10880-016-9471-x

Cultural Humility and Hospital SafetyCulture

Joshua N. Hook, David Boan, DonE. Davis, Jamie D. Aten, John M. Ruiz &Thomas Maryon

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Cultural Humility and Hospital Safety Culture

Joshua N. Hook1 • David Boan2 • Don E. Davis3 • Jamie D. Aten2 •

John M. Ruiz4 • Thomas Maryon5

! Springer Science+Business Media New York 2016

Abstract Hospital safety culture is an integral part ofproviding high quality care for patients, as well as pro-

moting a safe and healthy environment for healthcare

workers. In this article, we explore the extent to whichcultural humility, which involves openness to cultural

diverse individuals and groups, is related to hospital safety

culture. A sample of 2011 hospital employees from fourhospitals completed measures of organizational cultural

humility and hospital safety culture. Higher perceptions of

organizational cultural humility were associated withhigher levels of general perceptions of hospital safety, as

well as more positive ratings on non-punitive response to

error (i.e., mistakes of staff are not held against them),handoffs and transitions, and organizational learning. The

cultural humility of one’s organization may be an impor-

tant factor to help improve hospital safety culture. Weconclude by discussing potential directions for future

research.

Keywords Culture ! Humility ! Safety ! Hospital !Organization

Introduction

Patient safety, which refers to the avoidance and preventionof patient injuries or adverse events resulting from the

processes of health care delivery, is a critical component of

health care quality. Organizational processes such as safetyexist within the social context of an organization. This

social context is known as the culture of the organization,

and hospital safety culture supports or constrains processesthat provide for the safety of patients and staff. For

example, a culture that supports non-punitive error

reporting is likely to positively affect the safety of patientsand staff; however, a culture in which staff feel as if their

mistakes are held against them may negatively affectsafety. As a result, there has been increased focus among

hospitals and health care providers to promote a culture and

environment that prioritizes and values patient safety. Thisincreased focus has led to efforts to assess and measure

hospital safety culture, such as the Agency for Healthcare

Research and Quality (AHRQ) Hospital Survey of PatientSafety Culture (Sorra, Famolaro, Yount et al., 2014).

Although there have been important advances in regard to

the assessment and measurement of hospital safety culture,more work is needed to identify characteristics of hospitals

& Joshua N. [email protected]

David [email protected]

Don E. [email protected]

Jamie D. [email protected]

Thomas [email protected]

1 Department of Psychology, University of North Texas, 1155Union Circle #311280, Denton, TX 7520, USA

2 Department of Psychology, Wheaton College, 501 CollegeAve., Wheaton, IL 60187, USA

3 Department of Counseling and Psychological Services,Georgia State University, 33 Gilmer St. SE, Atlanta,GA 30303, USA

4 Department of Psychology, University of Arizona, 1503 E.University Blvd., Tuscon, AZ 85721, USA

5 Blue Cross/Blue Shield, 1001 E. Lookout Dr., Richardson,TX 75082, USA

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J Clin Psychol Med Settings

DOI 10.1007/s10880-016-9471-x

Author's personal copy

that contribute to hospital safety culture. The present

investigation targets cultural humility as one potentialcharacteristic that may be important to hospital safety

culture.

Hospital Safety Culture

Hospital safety culture has received extensive coverage in

the professional literature and among healthcare organi-

zations attempting to improve their performance related topatient and staff safety. Hospital safety culture refers to

‘‘management and staff values, beliefs, and norms aboutwhat is important in a health care organization, how

organization members are expected to behave, what atti-

tudes and actions are appropriate and inappropriate, andwhat processes and procedures are rewarded and punished

with regard to patient safety’’ (Sorra & Dyer, 2010).

Hospital safety culture is characterized by (a) a foundationof mutual trust, (b) a shared view that patient safety is

important, and (c) a belief that preventative measures are

effective (Groves, 2014).The connection between organizational safety culture

and performance has some limited evidence across indus-

tries (Molenar, Park, & Washington, 2009), but has largelybeen challenging to quantify, and has been criticized for

focusing too narrowly on social interactions within the

organization and ignoring larger contextual factors(Guldenmund, 2010; Naevestaad, 2009). Despite these

challenges, there is some evidence that hospital safety

culture is associated with actual hospital performance. Forexample, perceptions of hospital safety culture are related

to the injuries experienced by staff (Grytdal, Kobeski,

Kaplan, Flanagan, & Cousin, 2006). Specifically, hospital-based healthcare personnel who had more positive per-

ceptions of hospital safety culture were less likely to have

had a sharp injury in the past 12 months (Grytdal et al.,2006). Also, hospital safety culture has been linked to

patient safety outcomes such as lower rates of in-hospital

complications and adverse events (Mardon, Khanna, Sorra,Dyer, & Famolaro, 2010).

Hospital Safety Culture and Cultural Differences

Patient care and safety may be compromised if health careworkers fail to appreciate and understand patients who

identify as racial/ethnic minorities. Indeed, disparities in

quality of care and health status are persistent problems inthe United States. The 2014 National Healthcare Quality

and Disparities Report (Agency for Healthcare Research

and Quality [AHRQ], 2015) stated that although healthcareaccess and quality (including patient safety) have improved

in recent years, parallel gains in access and quality across

groups resulted in continued disparities. People who werepoor experienced the largest number of disparities, fol-

lowed by Blacks and Hispanics (AHRQ, 2015).

Brach and Fraserirector (2000) proposed a model thattheoretically linked nine aspects of cultural competency to

reduced health disparities for racial/ethnic minority

patients: interpreter services, recruitment and retention,training, coordinating with traditional healers, use of

community health workers, culturally competent healthpromotion, including family and/or community members,

immersion into another culture, and administrative and

organizational accommodations. Unfortunately, with theexception of interpreter services, which has evidence sup-

porting its effectiveness in reducing health disparities,

Brach and Fraserirector (2000) concluded ‘‘there is little byway of rigorous research evaluating the impact of partic-

ular cultural competency techniques on any outcome,

including the reduction of racial and ethnic disparities…Most linkages among cultural competency techniques, the

processes of health care service delivery, and patient out-

comes have yet to be empirically tested’’ (p. 203). In recentyears, there have been several studies that have explored

the effectiveness of interventions designed to improve

cultural competency in health care workers (see Beachet al., 2005 for a review). However, there have been rela-

tively few studies that have linked cultural competency

training to actual patient outcomes (Lie, Lee-Rey, Gomez,Bereknyei, & Braddock, 2011). It is clear that more

research linking aspects of cultural competence to patient

care is needed.One characteristic of hospitals that may be especially

important for promoting hospital safety culture with racial/

ethnic minority patients is cultural humility. Humilityincludes both intrapersonal and interpersonal components

(Davis et al., 2011, 2013). On the intrapersonal level,

humility involves an accurate view of self, including anawareness and acknowledgement of one’s limitations. On

the interpersonal level, humility involves an interpersonal

stance that is other-oriented rather than self-focused.Cultural humility is a subdomain of humility that

focuses specifically on cultural differences (Hook, Davis,

Owen, Worthington, & Utsey, 2013). On the intrapersonallevel, cultural humility involves an accurate view of one-

self culturally, including awareness of the limitations of

one’s own cultural perspective and one’s ability to under-stand another person’s cultural background and experience.

On the interpersonal level, humility involves openness to

the other person’s cultural background, characterized byrespect and lack of superiority. Individuals with high levels

of cultural humility are open to the idea that other indi-

viduals and groups may differ in their beliefs, values, andattitudes, and seek to respect and perhaps even celebrate


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these differences rather than trying to force culturally dif-

ferent individuals and groups to conform to one particularworldview.

Most of the empirical research on cultural humility has

occurred in the context of psychotherapy (Hook et al.,2013, 2016; Owen et al., 2014). For example, in a series of

four studies, Hook et al. (2013) found that (a) psychother-

apy clients viewed cultural humility as an important aspectof their therapist and (b) client perceptions of therapist

cultural humility were positively related to having a strongworking alliance and ultimately client improvement. Sec-

ond, Owen et al. (2014) replicated the findings of Hook

et al. (2013), and also found that cultural humility may beespecially important for aspects of the client’s cultural

background that are very important. Specifically, they

found that therapist cultural humility toward a client’sreligious worldview was positively related to client out-

comes, but this relation was stronger for clients with high

levels of religious commitment. Finally, Hook et al. (2016)examined the relation between cultural humility and racial

microaggressions (i.e., subtle type of covert racism con-

sisting of brief, everyday exchanges that send denigratingmessages to racial/ethnic minorities, Sue et al., 2007).

Therapists who were perceived to be high in cultural

humility committed fewer racial microaggressions than didtherapists who were perceived to be low in cultural

humility.

Although the empirical research thus far on culturalhumility has occurred in the context of psychotherapy,

researchers have begun to theorize that cultural humility

may be important in medical settings as well. Forexample, Tervalon and Murray-Garcia (1998) proposed

that cultural humility was a key goal in multicultural

medical education. In this context, cultural humility isless focused on one’s cultural knowledge, and more

focused on developing a ‘way of being’ with patients that

values, honors, and respects the patient’s cultural back-ground and experiences. They defined cultural humility as

involving a lifelong commitment to: (1) self-evaluation

and critique, (2) redressing the power imbalances in thephysician-patient dynamic, and (3) developing mutually

beneficial and non-paternalistic partnerships with

communities.The purpose of the present study is to investigate the

relation between organizational cultural humility and

hospital safety culture. Prior research on cultural humilityhas focused on the context of psychotherapy (Hook et al.,

2013); in this study, we extended this research to the

hospital setting. Based on previous theory that has pro-posed cultural humility to be an important aspect of

medical training and education (Chang, Simon, & Dong,

2012; Tervalon & Murray-Garcia, 1998), we propose thatcultural humility may be an important concept for

understanding and improving a hospital organization’s

safety culture. We hypothesized that perceptions of orga-nizational cultural humility would be positively related to

general perceptions of safety, as well as ratings of

important hospital safety culture variables. Specifically,we focused on two hospital safety culture variables that

were deemed areas for improvement based on low average

positive responses (i.e., non-punitive response to error andtransitions; Agency for Healthcare Research and Quality

[AHRQ], 2014), as well as one hospital safety culturevariable that was theoretically linked to the concept of

cultural humility (i.e., organizational learning—continuous

improvement).

Method

Participants and Procedure

Participants were 2011 hospital employees recruited from

four large hospitals in the Midwest United States. In regard

to job role, 78.6 % of participants were front-lineemployees (e.g., nurses, technicians, clerical staff). The

rest of the same was comprised of mid-managers (14.1 %),

senior executives (1.2 %), and physicians (6.2 %). Partic-ipants worked in a variety of units (15.8 % no specific unit,

8.0 % surgery, 6.3 % non-surgical medicine, 5.6 % emer-

gency department, 4.9 % obstetrics, 4.9 % psychia-try/mental health, 4.5 % laboratory, 4.1 % radiology,

3.2 % pharmacy, 2.9 % rehabilitation, 2.7 % intensive care

unit, 1.6 % pediatrics, 1.1 % anesthesiology, and 34.2 %other).

The hospitals in the present study were participants in a

national project to improve hospital healthcare perfor-mance called the Partners for Performance (PFP). Mem-

bers of the project who were planning to complete the

AHRQ Hospital Survey of Patient Safety Culture wereinvited to also complete the cultural humility survey.

Recruitment started with presenting the cultural humility

instrument as part of a webinar on culture and healthdisparities. PFP staff then received and responded to

inquiries about the instrument and invited interested hos-

pitals to participate in the survey process. The survey wascompleted online and included informed consent and a

discussion of how the confidentiality of survey results

would be protected. Participants received their individual(i.e. hospital level) results of the cultural humility survey

along with other survey results, copies of the literature

supporting the instrument, and suggestions on how tofollow up on the survey results. Additionally and as part of

the PFP program, all participants received a phone

debriefing on the survey results. No individual results werereported.


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Measures

Cultural Background

Participants completed a single-item measure that asked:

What aspect of your cultural background is most central orimportant to you? Responses included race/ethnicity, gen-

der, religion, sexual orientation, age, disability, socioeco-

nomic status, and other.

Organization Cultural Humility

Participants completed a modified version of the cultural

humility scale (Hook et al., 2013). The scale has 12 items.

The lowest possible mean score is 1, and the highest pos-sible mean score is 5. Higher scores indicate higher levels

of perceived cultural humility. Typical items are ‘‘Asks

questions when he/she is uncertain’’ and ‘‘Is open toexplore’’. Participants were given the following instruc-

tions: ‘‘Please think about your organization. Think about

the culture of your organization generally, or how mostpeople from your organization act. Using the scale below,

please indicate the extent to which you agree or disagree

with the following statements about individuals from yourorganization, regarding different aspects of culture.’’

Responses ranged from 1 = strongly disagree to

5 = strongly agree. Scores on the CHS have shown evi-dence for reliability and validity (Hook et al., 2013). For

the current sample, the Cronbach’s alpha coefficient was

.91.

Hospital Safety Culture

Participants completed the Hospital Survey on Patient

Safety Culture (Sorra & Nieva, 2004). This survey was

designed to assess hospital staff opinions about patientsafety issues, medical errors, and event reporting. Partici-

pants were given the following instructions: ‘‘Your hospital

has arranged for you to complete the AHRQ HospitalSurvey on Patient Safety Culture in order to measure and

improve your hospital’s safety culture. Your responses to

the survey are the only data collected and retained by thisform. The focus of the survey is the hospital where you are

employed or serve on medical staff. An ‘‘event’’ is defined

as any type of error, mistake, incident, accident, or devia-tion, regardless of whether or not it results in patient harm.

‘‘Patient safety’’ is defined as the avoidance and prevention

of patient injuries or adverse events resulting from theprocesses of health care delivery.’’

The survey has 42 items, which are separated into 12subscales. Each subscale had acceptable levels of internal

consistency, with the exception of the staffing subscale

(Sorra & Dyer, 2010). For the present study, we focused on

four subscales. For each subscale, the lowest possible mean

score is 1, and the highest possible mean score is 5. Higherscores indicate higher levels of hospital safety culture.

Responses ranged from 1 = strongly disagree to

5 = strongly agree.First, we examined a subscale that assessed general

perceptions of safety. This subscale has 4 items. Typical

items are ‘‘Patient safety is never sacrificed to get morework done’’ and ‘‘Our procedures and systems are good at

preventing errors from happening’’. For the current sample,the Cronbach’s alpha coefficient was .74.

Second, we examined two subscales that were deemed

areas for improvement, based on their lowest averagepositive responses from over 6000 hospitals across the

United States (AHRQ, 2014). The first ‘area for improve-

ment’ subscale was non-punitive response to error. Thissubscale has 3 items. Typical items are ‘‘Staff feel like their

mistakes are held against them’’ (reverse coded) and

‘‘When an event is reported, it feels like the person is beingwritten up, not the problem’’ (reverse coded). For the

current sample, the Cronbach’s alpha coefficient was .82.

The second ‘area for improvement’ subscale was handoffsand transitions. This subscale has 4 items. Typical items

are ‘‘Things ‘fall between the cracks’ when transferring

patients from one unit to another’’ (reverse coded) and‘‘Important patient care information is often lost during

shift changes’’ (reverse coded). For the current sample, the

Cronbach’s alpha coefficient was .86.Third, we examined the organizational learning—con-

tinuous improvement subscale, which was theoretically

linked to our concept of cultural humility. This subscalehas 3 items. Typical items are ‘‘We are actively doing

things to improve patient safety’’ and ‘‘Mistakes have led

to positive changes here.’’ For the current sample, theCronbach’s alpha coefficient was .73.

Statistical Analysis

For our preliminary analyses, we reported descriptivestatistics, including means, standard deviations, and inter-

correlations among study variables. Our primary research

question was to investigate the extent to which ratings oforganization cultural humility predicted ratings of hospital

safety culture using hierarchical multiple regression. We

used four hierarchical multiple regression analyses, withgeneral perceptions of safety and the three hospital safety

culture subscales (i.e., non-punitive response to error,

handoffs and transitions, and organizational learning—continuous improvement) as dependent variables. Because

the data are grouped as individuals nested within hospitals,

we included three dummy-coded hospital variables ascovariates in Step 1 of all analyses. The hospital with the


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largest number of participants was used as the reference

group. Ratings of hospital cultural humility were includedas a predictor in Step 2.

Results

Participants listed a range of cultural identities that weremost central or important to them, including religion

(35.3 %), race/ethnicity (20.9 %), age (17.6 %), gender

(15.0 %), socioeconomic status (8.0 %), disability (2.2 %),and sexual orientation (0.9 %). Means, standard deviations,

and inter-correlations among study variables are inTable 1.

Cultural humility was a significant positive predictor of

perceptions of safety. Table 2 summarizes this analysis. InStep 1, there were significant differences based on hospital,

which accounted for about 3 % of the variance in overall

perceptions of patient safety (R2 = .03, p\ .001). In Step2, controlling for overall hospital differences, perceptions

of organization cultural humility were positively associated

with perceptions of patient safety, and accounted for anadditional 20 % of the variance (DR2 = .20, p\ .001).

Cultural humility was also a significant positive pre-

dictor of non-punitive response to error. Table 3 summa-rizes this analysis. In Step 1, there were significant

differences based on hospital, which accounted for about

1 % of the variance in non-punitive response to error(R2 = .01, p = .004). In Step 2, controlling for overall

hospital differences, perceptions of organization cultural

humility were positively associated with non-punitiveresponse to error, and accounted for an additional 18 % of

the variance (DR2 = .18, p\ .001).

Cultural humility was also a positive predictor ofhandoffs and transitions. Table 4 summarizes this analysis.

In Step 1, there were no significant differences based on

hospital (R2 = .00, p = .129). In Step 2, controlling foroverall hospital differences, perceptions of organization

cultural humility were positively associated with handoffs

and transitions, and accounted for an additional 15 % of thevariance (DR2 = .15, p\ .001).

Cultural humility was also a positive predictor of

organizational learning—continuous improvement.

Table 5 summarizes this analysis. In Step 1, there were

significant differences based on hospital, which accountedfor about 2 % of the variance in organizational learning—

continuous improvement (R2 = .02, p\ .001). In Step 2,

controlling for overall hospital differences, perceptions oforganization cultural humility were positively associated

with organizational learning—continuous improvement,and accounted for an additional 21 % of the variance

(DR2 = .21, p\ .001).

Table 1 Descriptiveinformation and incorrelationsfor all variables

Variable M (SD) 1 2 3 4 5

1. Cultural humility 3.59 (.77) –

2. Overall perceptions of safety 3.71 (.79) .46* –

3. Nonpunitive response to error 3.04 (.97) .42* .51* –

4. Handoffs and transitions 3.26 (.83) .39* .47* .37* –

5. Organizational learning—continuous improvement 3.87 (.69) .47* .58* .41* .37* –

* p\ .001

Table 2 Hierarchical regression analysis predicting general percep-tions of safety

Predictor DR2 b sr2

Step 1 .03*

D_Hospital 2 -.06 .00

D_Hospital 3 -.19* .03


Step 2 .20*

D_Hospital 2 .00 .00



Cultural humility .45* .20

* p\ .001

Table 3 Hierarchical regression analysis predicting non-punitiveresponse to error

Predictor DR2 b sr2

Step 1 .01




Step 2 .18*

D_Hospital 2 .10* .01




* p\ .001


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Discussion

The purpose of this study was to examine the associationbetween perceptions of organization cultural humility and

perceptions of hospital safety culture. We examined gen-

eral perceptions of hospital safety, two aspects of hospitalsafety culture that were deemed areas for improvement,

based on having the lowest average positive responses from

over 6000 hospitals across the United States (i.e., non-punitive response to error and handoffs and transitions;

AHRQ, 2014), and one aspect of hospital safety culture

that was theoretically linked with cultural humility (i.e.,organizational learning—continual improvement).

Overall, our findings were consistent with our hypoth-

esis that higher ratings of organization cultural humilitywould be positively associated with higher ratings of hos-

pital safety culture. This association held even when con-

trolling for mean differences across hospitals. Effect sizesfor the relationship between cultural humility and hospital

safety culture were moderate to large—cultural humility

predicted between 15 and 21 % of the variance in hospitalsafety culture ratings.

This is an important first step in exploring the possible

role of cultural humility in hospital settings. Hospitalemployees who viewed the members of their organizations

to be more culturally humble also reported better experi-

ences with hospital safety, including general perceptions ofsafety, non-punitive response to error, handoffs and tran-

sitions, and organizational learning—continual improve-ment. Thus, cultural humility practiced in the medical

context may contribute to (1) style of communicating,

which affects rapport, accurate diagnosis, and facilitates anon-paternalistic approach; (2) cooperation, which affects

rapport, adherence, and partnership building; (3) health

beliefs, especially those different from the provider’s, andthose that emphasize self-evaluation; and (4) better iden-

tifying and addressing psychosocial factors related to pain,

anxiety, and depression. These all contribute to patientsafety needs beyond traditional indicators such as medical

errors, adverse events, and infection rates.

Although this is the first study to our knowledge toexamine the role of cultural humility in the context of

hospital safety culture, our findings are consistent with past

theory and research on the role of cultural humility andhealthcare (Chang et al., 2012; Tervalon & Murray-Garcia,

1998). Furthermore, it supports a growing body of research

showing that cultural humility plays an important role inthe helping professions (Davis et al., 2016; Hook et al.,

2013, 2016; Owen et al., 2014).

There were several limitations to the present study. First,the data were cross-sectional, which precludes causal

inferences. Although the data are consistent with our the-

oretical model (i.e., cultural humility leading to betterhospital safety culture), other causal models are possible

(e.g., positive hospital safety culture leading to higher

ratings of cultural humility). Longitudinal and experimen-tal research is necessary to elucidate the causal connections

between these variables. Second, we used self-report

measures of cultural humility and hospital safety culture.Although both measures had high levels of internal con-

sistency and past evidence for validity, there are limitations

to self-report measures, including social desirability biasand other types of response bias (e.g., yea-saying). Future

research should incorporate other types of measures, such

as other-report or behavioral measures (Dorn, Hook, Davis,Van Tongeren, & Worthington, 2014). Third, due to limi-

tations in our data collection process, we did not gather

demographic data such as race, gender, and socioeconomicstatus. Future research should gather these data to provide a

clearer context to interpret the findings. Fourth, we utilized

a limited number of hospitals, and thus were unable toassess the effect of hospital characteristics (e.g., population

Table 4 Hierarchical regression analysis predicting handoffs andtransitions

Predictor DR2 b sr2

Step 1 .00




Step 2 .15*





* p\ .001

Table 5 Hierarchical regression analysis predicting organizationallearning—continuous improvement

Predictor DR2 b sr2

Step 1 .02*




Step 2 .21*





* p\ .001


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of city, % non-white, rural vs. urban, etc.) on perceptions of

cultural humility or hospital safety culture.In addition to utilizing more intensive research designs

and measurement strategies, there are several exciting

areas for future research. First, the current study examinedratings of cultural humility of the organization as a whole.

Future research could explore ratings of cultural humility

of particular individuals, such as doctors or work supervi-sors. Second, the current study examined one important

outcome (i.e., hospital safety culture), but future researchcould explore other outcomes, such as actual patient out-

comes or patient satisfaction ratings. Third, qualitative

research could explore in more depth what culturalhumility actually looks like in hospital interactions, and

what aspects of cultural humility are most important to

hospital workers and patients. Finally, cultural humilityinterventions could be developed and implemented into

medical training as a strategy to improve hospital safety

culture. The effects of these interventions on hospital andpatient outcomes could then be measured.

Improving hospital safety culture is an important aim as

hospitals attempt to provide high-quality medical care to allindividuals. In the present study, we found that perceptions

of organization cultural humility may be an important

factor to consider in regard to this aim. Indeed, culturalfactors have been understudied in research that explores

effective health care in the medical setting. The problem of

racial/ethnic disparities in health care is a major issue thatthe medical field must wrestle with as the United States

becomes increasingly diverse. It is important to provide the

highest quality of care to all individuals, irrespective oftheir cultural background. In the present investigation, we

presented cultural humility as one potential characteristic

of individuals and hospitals that may contribute to high-quality care for culturally diverse individuals and groups.

Compliance with Ethical Standards

Conflict of Interest Joshua N. Hook, David Boan, Don E. Davis,Jamie D. Aten, John M. Ruiz, and Thomas Maryon declare that theyhave no conflict of interest.

Human and Animal Rights and Informed Consent All proceduresperformed in studies involving human participants were in accor-dance with the ethical standards of the Institutional and/or NationalResearch Committee and with the 1964 Helsinki declaration and itslater amendments or comparable ethical standards. Informed consentwas obtained from all individual participants included in the study.

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