Implicit as compared with explicit safety procedures: the experiences of Israeli nurses

Approaches to nurses' safety in health care organizations, including modifying individual behavior through enforced compliance with safety rules and mandatory participation in safety training, have been of only modest benefit in reducing injuries. Apparently, what matters is not the existence of guidelines, but their implementation. The aim of the present study was to explore nurses' implicit safety theories concerning when to comply with safety rules. Using a multimethod approach, including semistructured interviews (perceptions), observations (real-time behavior), and documentary evidence from 15 nursing units (90 nurses), we found that nurses developed implicit rules for when and how to protect themselves. These included: (a) continue providing care for the patient even at the price of protecting yourself, (b) do not disturb other nurses' work, (c) it cannot happen to me!, (d) be aware of recently occurring accidents, and (e) protect yourself when significant others are present. These implicit rules seemed to be reinforced by personal, social, and contextual factors at the unit, limiting the likelihood that the decision makers (nurses) would discover their fallacy.