Cory Worden, M.S., CSHM, CSP, CHSP, ARM, REM, CESCO and Kelley Lombardo, MEd
Within the scope and context of high-reliability safety cultures, hazard control extends into a third dimension of situational awareness beyond conditions and behaviors. While safe conditions are both required by regulatory compliance measures (OSHA, n.d.) as well as promulgated by national consensus standards and provide basic hazard control mechanisms for stagnant hazards such as machinery points of operation, they only provide the pretense for safe behaviors. Safe behaviors, an extension of safe conditions, require safe conditions and their associated hazard controls to set the foundation for a safe environment while appropriate operating procedures are followed. For example, while a machine guard provides the baseline safe condition for use of a piece of machinery, safe behaviors require employees to both use the machine guard (safe condition) and follow the machinery’s standard operating procedure (SOP), lock-out-tag-out (LOTO) procedure and more to maximize those safe conditions through safe behaviors. Between these two realms of safety, organizations will have set the precedent for safe operations as well as the expectations for safety within their organization. In short, organizations that have analyzed hazards to put appropriate hazard controls in place for safe conditions and expectations and procedures for safe behaviors will have done due diligence in setting employees up for success regarding safety. Continual efforts in information programs and communication, leading indicators for oversight of conditions and behaviors through inspections and observations, incentive programs and follow-up to incidents through investigations and analyses can then allow for a more maximized effort. However, the dichotomy still remains as this paradigm exists for stagnant hazards. For example, a piece of machinery is operating the same way each day; as long as the guard remains in place and the SOP is followed, safe work can be expected. However, within other, more volatile fields such as the military, law enforcement, fire protection and healthcare, the third dimension of situational awareness exists and provides the context by which hazard control must take place. Even with the safest possible conditions and the safest behavioral expectations, none of this matters if employees cannot assess situations, identify hazards and make safety decisions – in real time. Only with this situational awareness can high-reliability operations take place.
Tracing the Cord Back to the Wall
Figure A – The path from ERM to situational awarerness (strategic to tactical safety)
Organizational safety cultures don’t, contrary to many beliefs about individual employee accountability, begin and end at the tactical level. If unsafe conditions and/or unsafe behaviors exist, this is likely a by-product of the organization’s upper-echelon stance on safety and risk. Within an enterprise risk management (ERM) culture, organizations determine what risks – the potential to lose or gain at any time based on different variables – they’re willing to live with. Some of these risks are avoided altogether while others are transferred via contracts, insurance or other means. Some risks are accepted. The rest of the risks are deemed controllable (Institutes, n.d.). At this point, those risks deemed controllable are assessed via the Hierarchy of Controls where regulatory compliance is required, safe conditions can be made and safe behavioral expectations can be developed (Goetsch, 2011). At this point, organizations will have ideally set the precedents for safe operations through basic foundations for employees to make safe decisions when nobody is around to tell them otherwise. It’s also at this point that the organization can decide whether it will maintain itself with the bare minimum safe culture (‘the government is making me work safely’), whether it will implement and enforce expectations of safe behaviors in addition to maintaining safe conditions (‘the System is making me work safely’) or whether it will actively validate safe behaviors and conditions through increased diligence in safety observations, inspections and more, including functions of Wilson and Higbee’s (2012) dangerous states of mind and critical errors.
Figure B – What it takes to control a workplace hazard
Art and Science
At this point, many organizations will have set the foundational elements for safe work practices in a stagnant environment. Working with machines that operate the same way every shift, every day, the maintenance of safe conditions (housekeeping and inspections) along with observations of safe behaviors based on pre-determined SOPs just may do the trick to keep people working safely. There may be few, if any, variables to consider in making safe decisions aside from personal accountability issues such as decisions to not don PPE or the like. However, in fields such as the military, law enforcement, fire protection, healthcare, aviation and more, situational awareness is the possible single point failure that can enable or completely negate safety.
Even in a stagnant environment, human error plays an enormous part in safe work practices. Even with safe conditions maintained and safe behavior expectations put in place, people still have to be relied on to follow them. While safe conditions and the elimination, substitution and, to a degree, engineering control subsets of the Hierarchy of Controls (Goetsch, 2011) are scientific in nature, the leadership required to guide employees towards safe behaviors is an art form. By definition, this art is difficult to handle and even more difficult to teach.
Figure C – Art and science
When this art evolves from leading employees to follow pre-existing SOPs into making real-time decisions to identify, assess and control and/or respond to hazards and threats, it becomes even more difficult. In many contexts, what are now considered high-reliability fields were not highly reliable for this reason. Military aviation, now a benchmark industry of high-reliablity processes, once yielded a higher chance of dying in a non-combat accident than otherwise. Hillenbrand (2010) details this in her Unbroken book with a note of 52,651 stateside aircraft accidents and 14,903 fatalities due to “pilot and navigator error, mechanical failure, and bad luck” (Hillenbrand, 2010, p. 66). Meantime, Coram (2002) notes the F-100 fighter aircraft in the mid-1950’s and the aircraft’s issues with its nose pulling during takeoff or acceleration, airflow discrepancies to the engine causing compressor stalls and adverse yaw in which too much aileron use caused the aircraft to pitch the opposite direction as intended – causing accident losses totaling a quarter of F-100 aircraft ever produced. During the 1980 rescue attempt of the American hostages in Iran known as Operational Eagle Claw, the mission was aborted when a helicopter tore through the fuselage of an EC-130 aircraft prior to the mission launch (Beckwith, 1983). Even after intensive selection and training procedures, Navy SEAL teams have had training incidents in which team members were shot during live fire exercises (Williams, 2010). However, as the years progressed and lessons were learned from these tragic occurrences, developments were made to not only benefit the mechanics of the equipment involved (safe conditions) but also the abilities of those involved to develop situational awareness so that, regardless of the situation, they could better equip themselves to adapt to the variables and remain safe.
John Boyd’s OODA Loop
Originally developed by Colonel (Retired) John Boyd of the U.S. Air Force, his Observe-Orient-Decide-Act (OODA) Loop was developed for use in aerial combat so that pilots would have a mechanism to observe for enemy aircraft, orient to their positions, make real-time decisions as to reactions and execute (act) them before being killed. This real-time OODA Loop gave context to the mentality required in combat to stay a proverbial one step ahead of those trying to kill you. Boyd’s OODA Loop, seemingly unpopular at first, was later adopted by the U.S. Marine Corps and applied to ground combat (Coram, 2002) and then by the U.S. Army as noted by those experienced in special operations (Howe, 2005). Later extended into Emergency Management and anti-terrorism apparatuses (Maccuish, 2012), Boyd’s OODA Loop continues to provide a context by which real-time decisions can be made to identify hazards and threats and respond accordingly before a negative outcome occurs. However, the most beneficial part of the OODA Loop is that it directly addresses the situational awareness realm of hazard control in any environment. Regardless of the industry or situation, the OODA Loop provides the means to exercise the mind and stimulate situational awareness in any context. For example, the graphics below demonstrate the use of the OODA Loop in the healthcare setting where nurses are routinely exposed to hazards such as workplace violence and occupational disease exposures.
Figure D – John Boyd’s OODA Loop as applied to healthcare workplace violence prevention
Figure E – John Boyd’s OODA Loop as applied to healthcare occupational disease exposure prevention
Developing Situational Awareness
The military service has a long and illustrious history of indoctrination processes beginning with their various basic training – ‘boot camp’ – programs. Robert Leckie (1957) describes his experience in World War II Marine Corps basic training as having no pattern or methodology, only to build subordination to the point in which he believed the Marine Corps to be madness, a feat that would later keep him alive in combat in the Pacific. Couch (2007) details the scenario-driven exercises undergone by candidates for the U.S. Army Special Forces in counterinsurgency and working with indigenous personnel in embedded operations. Gresham (2006) also details the intensive training requirements undergone by students at the U.S. Army’s JFK Special Warfare Center in not only academic knowledge but practical application of shooting, insertion techniques, foreign languages and other methods of not only fighting but integrating into the combat environment at hand. These few examples help illustrate the precedent for developing not only knowledge, skills and abilities among those expected to enter intrinsically volatile and unsafe situations but also abilities to make safety decisions in real-time. Without these indoctrination processes, these personnel would be set up to fail, a failure that could cost them their lives. Similar indoctrination processes exist in the law enforcement community (Police Academy), the fire protection community (Fire Academy, EMS/Paramedic Training) and more.
How Adults Learn
In terms of addressing this development of situational awareness, this extends well beyond academic knowledge and traditional student evaluation techniques. Adult education and learning theories state…….?
The Healthcare Dilemma
While the military, law enforcement and fire protection communities have definitive processes in place for not only training but for overall indoctrination into the professional culture and the need for situational awareness, the healthcare community as a whole does not. In greater terms, many new nurses can expect to transition directly from a higher-learning institute to an acute-care hospital, even to an Emergency Department, with little or no orientation other than to patient care protocols. In this respect, basic hazard controls may or may not be in place. If the healthcare organization is diligent, safe conditions will be maintained via inspections and housekeeping (generally enforced by The Joint Commission or a similar function as well as OSHA) as well as procurements of hazard controls such as PPE, safe needle devices (safety latches, retractable devices and the like), respirators, patient handling equipment and more. However, these safe conditions don’t necessarily mean employees will use them; more diligent organizations will have implemented processes to validate expectations of safe behaviors such as actually using PPE, safety devices and equipment and more. However, none of this accounts for the real-time assessment of each patient that determines the minute-to-minute need for PPE use, patient handling equipment, respirators and more. This is where situational awareness must become a trained and indoctrinated factor in the healthcare community.
The Workplace Violence Example
Workplace violence is an example that shows itself on a consistent basis. Should a nurse not be conditioned to assess each patient for potential workplace violence, he or she could find themselves pinned in the back corner of a patient room before he or she even realizes the danger. At this point, calling a code or shouting for Security would be an effort too late. Instead, diligence on the hospital’s behalf would allow for rooms to be set up with the nurse always between the patient and the egress point. Each nurse would be trained and conditioned to assess each patient for potential violence. Should there be any chance of violence, proactive measures would be taken such as placing Security on standby. Should violence become a reality, the nurse would have already been in a position that the egress point of the room was available to them and the nurse would have maintained reactionary distance from the patient. At this point, Security could be called without the nurse being placed in a violent position. Should the nurse be forced into a violent situation, that nurse would have been trained and conditioned in reactionary techniques to break free from the situation and egress the area. There are several proverbial moving parts to this scenario, all of which must be accounted for to actually control the hazard. However, without the situational awareness to identify the hazard in the first place, none of the other parts can happen (Worden, 2014).
Training and Conditioning
The healthcare community has no precedent for indoctrinating, training and conditioning team members for the ever-present possibilities of life-threatening hazards in the healthcare workplace. Knowing the hazards they face on an everyday basis, police, fire department and military personnel are required to not only go through basic training processes but also extensive technical training and pre-deployment processes to develop a safety mindset. With its unfortunate 6.2 per 100 employee recordable rate within the United States (BLS, 2015), the healthcare community is obviously not only faced with a hazardous workplace but is sustaining a loss history because of it. Nursing turnover and nurses leaving the field altogether are going up every year (ANA, n.d.). Based on adult education and learning theory as well as best practices in other industries, there is no alternative but to invest in our teammates’ success through the hard work of mentally preparing them to make real-time decisions that could save their lives or prevent an injury or exposure. This has to be an extension of the art and science of safety within regulatory compliance, hazard control and safe behavior expectations and validation. However, without the situational awareness to support this, safety may only amount to luck on any given day.
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