• The relationship between management and employees is respectful and supportive.

• Awareness of the impact of cultural issues is reflected in key decisions. The organization rewards not just those who produce, but also those who support the work of others. People are rewarded for improving processes as well as results.

The characteristics of all three stages can serve organizations as a basis for self-diagnosis. They can also be used by an organization to give direction to its development of a safety culture by identifying its current position and the position to which it aspires. It should be noted that an organization at any given point in time may exhibit a combination of the characteristics listed under each stage and that different departments or other components of an organization may be at different stages.

The time required for an organization to progress through the three stages cannot be predicted. Much will depend on the circumstances of an individual organization and the commitment and effort it is prepared to devote to effecting change. However, sufficient time must be taken in each stage to allow the benefits from changed practices to be realized and to mature. People must be prepared for such change. Too many new initiatives in a relatively short period of time can be organizationally destabilizing. The important point to note is that any organization interested in improving its safety culture should start and not be deterred by the fact that progress will be gradual (Carnino, undated). HCOs should also expect to face a number of barriers unique to health care and the work environment of nurses.

As HCOs undertake the creation of a culture of safety, they must dedicate the internal personnel and other resources required to effect the needed changes. They must also deal with two barriers that must be overcome if they are to achieve the maximum benefit from their efforts—one that originates in the nursing profession (and also is found among other health professionals) and one that is found in the external legal/regulatory environment.

Nurses are trained to believe that clinical perfection is an attainable goal (Jones, 2002) and that “good” nurses do not make errors (Banister et