MCRXXX10.1177/1077558716629040Medical Care Research and ReviewDierynck et al.

research- article2016

Empirical Research
Medical Care Research and Review

The Role of Individual and 1–18

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DOI: 10.1177/1077558716629040
Promoting Occupational mcr.sagepub.com

Safety in Health Care

Bart Dierynck1, Hannes Leroy2,

Grant T. Savage3, and Ellen Choi4

Abstract
Although the importance of safety regulations is highly emphasized in hospitals, nurses
frequently work around, or intentionally bypass, safety regulations. We argue that work-
arounds occur because adhering to safety regulations usually requires more time and work
process design often lacks complementarity with safety regulations. Our main proposition
is that mindfulness is associated with a decrease in occupational safety failures through a
decrease in work-arounds. First, we propose that individual mindfulness may prevent the
depletion of motivational resources caused by worrying about the consequences of time
lost when adhering to safety regulations. Second, we argue that collective mindfulness
may provide nursing teams with a cognitive infrastructure that facilitates the detection and
adaptation of work processes. The results of a multilevel analysis of 580 survey responses
from nurses are consistent with our propositions. Our multilevel analytic approach enables
us to account for the unique variance in work-arounds that individual and collective
mindfulness explain.

Keywords
individual mindfulness, collective mindfulness, safety work-arounds,
occupational safety

This article, submitted to Medical Care Research and Review on September 9, 2015, was
revised and accepted for publication on January 5, 2016.

1Tilburg University, Tilburg, Netherlands

2RSM Erasmus, Rotterdam, Netherlands
3University of Alabama, Birmingham, AL, USA

4Ivey School of Business, London, Ontario, Canada

Corresponding Author:
Bart Dierynck, Tilburg School of Economics and Management, Tilburg University, PO
90153, Tilburg 5000 LE, Netherlands.
Email: b.dierynck@tilburguniversity.edu

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2 Medical Care Research and Review

Background
Occupational safety is a prominent issue in the management of organizations; indeed
managers in 118 countries contend that occupational safety is the number one social issue
that needs to be addressed (Kiron, Kruschwitz, Rubel, Reeves, & Fuisz-Kehrbach, 2013).
Although occupational safety is a costly and pervasive problem in many orga-nizations
(Zohar, 2010), the prevalence of occupational safety failures in hospitals is particularly
striking. Nurses, for instance, are 30 times more likely to experience an occupational
injury than workers in other industries (Lucian Leape Institute, 2013). A survey of nurses
in the United States revealed that almost one third had experienced back or
musculoskeletal injuries in the past year, and 13% reported unprotected con-tact with
blood-borne pathogens (Ulrich, Buerhaus, Donelan, Norman, & Dittus, 2005). Frequently
cited reasons for these alarming statistics include a turbulent work environment, the
increasing demands of the job, the complex and dynamic problems that nurses face, and
the need for continuous adaptation and learning (Katz-Navon, Naveh, & Stern, 2005;
Lucian Leape Institute, 2013).
In response to this prevalence of occupational injuries and inspired by the belief
that organizational reliability can be achieved through standardization and routines
(Hannan & Freeman, 1984), hospitals and both national and international organiza-
tions have enacted safety regulations for all types of actions (Brunsson & Jacobsson,
2000). Previous research, however, has documented that nurses often work around
these safety regulations. Some authors go as far as characterizing nurses as “mas-ters
of work-arounds,” recognizing that work-arounds are a common practice in health
care contexts (Morath & Turnbull, 2005). Consider, for example, nurses who attempt
to lift a patient on their own despite the safety regulations that call for either
assembling additional nurses to assist or using assistive equipment (e.g., a ceiling
mounted or portable lift). Such safety work-arounds, defined as the inten-tional
bypassing of existing safety regulations (Halbesleben, Wakefield, & Wakefield,
2008), are strong predictors of the frequency and severity of occupa-tional injuries in
hospitals (Halbesleben, 2010; Halbesleben & Rathert, 2008; Halbesleben, Savage,
Wakefield, & Wakefield, 2010). Notably, a single safety work-around may or may
not lead to an occupational injury; nevertheless, consis-tent engagement in safety
work-arounds does increase one’s risk of experiencing an occupational injury
(Halbesleben et al., 2008).
Hospitals strive for high levels of reliability in a context where even a small safety
failure can have detrimental consequences, making increasing occupational safety a
major concern. Prior research shows that safety-related behaviors are driven by
individual-level variables, such as personality characteristics and job attitudes, and team-
level antecedents, such as safety climate and leadership (Christian, Bradley, Wallace, &
Burke, 2009). Despite the fact that the interest in organizational and mana-gerial
cognition has increased in the past two decades, the literature on occupational safety has
largely ignored the role of cognition. Because several scholars have sug-gested that team
and individual cognition is key to assuring high performance in uncertain and complex
environments such as hospitals, it is important to examine

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Dierynck et al. 3

whether and how cognition-related constructs influence occupational safety in hospi-

tals (Walsh, 1995; Weick, Sutcliffe, & Obstfeld, 1999).
Recently, mindfulness has been proposed as a promising cognition-related con-
struct for predicting job performance (Dane & Brummel, 2013) and work-related
errors (Dane, 2011, 2013). A central aim of this article is thus to provide an empirical
account of the role of mindfulness in affecting occupational safety in hospitals.
Specifically, this study applies both individual and collective mindfulness as
cognitive antecedents to occupational safety. This multilevel perspective allows us to
account for the fact that both individual-level and team-level antecedents can drive
occupa-tional safety failures. We posit that mindfulness will decrease the occurrence
of work-arounds and, as such, increase occupational safety in hospitals. Unraveling
the relationship between mindfulness and occupational safety is important as some
evi-dence suggests that the degree of team and individual mindfulness can be
increased through implementing particular HR practices (Vogus & Welbourne, 2003)
and through mindfulness training (Brown & Ryan, 2003; Chambers, Lo, & Allen,
2008). However, despite these studies, presently there is a lack of empirical evidence
support-ing the efficacy of collective and individual mindfulness to improve safety
outcomes in hospitals making it difficult for hospital managers to make well-
informed decisions about whether to implement mindfulness-inducing HR practices
and mindfulness training.

New Contributions
Using multilevel modeling to separate between-subject effects (i.e., individual mind-
fulness) and between-group effects (i.e., collective mindfulness) as distinct sources
of variance in work-arounds, we tested our hypotheses on survey responses from 580
nurses (across 54 teams) to make two main contributions. First, we contribute to the
literature on occupational safety by providing empirical evidence for the role of team
and individual cognition in understanding occupational safety in hospitals. While
pre-vious research has documented that individual-level and team-level constructs
are important for understanding occupational safety (Christian et al., 2009), the
cognitive processes that influence occupational safety are understudied. By focusing
on indi-vidual and collective mindfulness as cognition-related constructs, our study
addresses this void to highlight the pivotal role of work-arounds in the relationship
between mindfulness and occupational safety in hospitals. We found evidence that,
while work-arounds make occupational safety failures more likely, both individual
and collective mindfulness are associated with lower rates of occupational safety
failures through fewer work-arounds. Importantly, we did not find a significant direct
effect for indi-vidual or collective mindfulness on occupational safety failures. This
emphasizes the significance of work-arounds as a lever to better understanding how
mindfulness can reduce occupational safety failures.
Second, this study adds to the growing evidence on the benefits of mindfulness in
organizations in general and hospitals in particular. Our results are in line with the view
that individual and collective mindfulness explain unique variance in work-arounds and

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4 Medical Care Research and Review

occupational safety failures in hospitals. Importantly, collective and individual mind-

fulness affect occupational safety but in relation to different constraints. Overall, the
results of this study suggest that increasing collective and individual mindfulness in
hospitals via mindfulness-inducing HR practices and mindfulness training may be
worthwhile interventions to improve occupational safety. Our aim is for the study’s
insights to have a considerable impact on the management of occupational safety in
hospitals.

Conceptual Framework
Individual Mindfulness
Given the high frequency of work-arounds in hospitals, a natural question to ask is
how a work environment replete with safety regulations might prompt nurses to
work around these regulations. One proposed explanation is that adhering to safety
regula-tions often entails the immediate cost of a slower pace (Naveh, Katz-Navon,
& Stern, 2005; Zohar, 2002). The slower pace caused by close adherence to safety
regulations increases the time pressure that nurses experience and may induce nurses
to start wor-rying about how they will be able to complete their work on time.
The main consequence of worrying about the future consequences of close adher-
ence to safety regulations is that the nurses’ motivational resources to adhere to the
safety regulations may be depleted (Halbesleben & Bowler, 2007). Because a lack of
motivational resources is a core predictor of work-arounds (Halbesleben, 2010), it
can be argued that the time-consuming characteristic of occupational safety
regulations can prompt nurses to work around them. We argue that individual
mindfulness will prevent the depletion of motivational resources caused by worrying
about the future consequences of adhering to safety regulations, thereby reducing
work-arounds and occupational safety failures.
Individual mindfulness has its roots in Buddhist philosophy and can be understood as
a state of consciousness in which one’s attention is focused on present-moment internal
and external phenomena. Individual mindfulness also manifests itself through an
accepting, open, and nonjudgmental attitude toward phenomena that are perceived in the
present moment (Brown & Ryan, 2003; Brown, Ryan, & Creswell, 2007; Dane, 2011;
Glomb, Duffy, Bono, & Yang, 2011). Like other psychological concepts, indi-vidual
mindfulness is a trait-level construct as well as a psychological state that varies from
moment to moment within individuals (Dane, 2011; Vogus, 2011). Hulsheger, Alberts,
Feinholdt, and Lang (2013), for instance, report that 62% of the variance in mindfulness
occurs between individuals and 38% within individuals. Contrary to pre-vious research
about attention, which has predominantly focused on the direction of attention,
mindfulness addresses the quality of attention and emphasizes the richness of the
interpretations that are based on perceiving present-moment phenomena (Dane, 2013;
Langer & Moldoveanu, 2000; Weick et al., 1999).
Shifting the line of inquiry from the direction of attention to the quality of attention
improves our chances of addressing why nurses work around the safety regulations.

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Dierynck et al. 5

Specifically, we argue that focusing attention on the present moment and approaching the
present moment with an accepting, open, and nonjudgmental attitude will reduce the
tendency of nurses to start worrying about the future consequences of adhering to time-
consuming occupational safety regulations. Consequently, the depletion of the nurses’
motivational resources is reduced implying that nurses will have more motiva-tional
resources available to closely follow the safety regulations. That is, we expect that
individual mindfulness will enable nurses to closely adhere to the occupational safety
regulations, ultimately resulting in a decrease in work-arounds. Overall, we expect
individual mindfulness will be related to fewer occupational safety failures among nurses
through a reduction in work-arounds.

Hypothesis 1: Individual mindfulness is related to fewer occupational safety fail-

ures among nurses through a reduction in safety work-arounds.

Collective Mindfulness
A second explanation for the prevalence of work-arounds is that the design of work
processes may conflict with newly developed safety regulations (Edmondson, 2004;
Halbesleben et al., 2008). For example, given the high degree of interdependence
among hospital departments, the design of work processes in other departments may
prevent nurses from adhering to the safety regulations in their own department
(Nembhard & Tucker, 2011; Tucker, Heisler, & Janisse, 2014). Working around
safety regulations is the dominant response of nurses in such situations, and previous
research shows that 10% to 15% of nurses’ work time is lost to managing the lack of
comple-mentarity between safety regulations and the design of work processes
(Tucker & Edmondson, 2002, 2003; Tucker et al., 2014). We argue that work-
arounds, and relat-edly, occupational safety failures, may be better understood when
they are considered from the perspective of collective mindfulness.
Collective mindfulness, also called mindful organizing, refers to an entirely differ-ent
construct than individual mindfulness. Collective mindfulness is defined as a team’s
capacity to develop a rich awareness of discriminatory details about internal and external
processes and to regulate team behaviors accordingly (Vogus, 2011; Vogus & Sutcliffe,
2012; Weick et al., 1999; Weick & Sutcliffe, 2006). Collective mindfulness can be
identified through five team processes (Weick & Sutcliffe, 2007):
(a) preoccupation with failure in noticing when something goes wrong, (b) reluctance to
simplify so that heuristics and “quick fixes” are avoided, (c) sensitivity to operations to
prevent automated processes from occurring in unexpected and undesirable ways,
(d) commitment to bounce back from failure and inaction, and (e) deference to exper-
tise to ensure that the person with the right qualifications executes the job.
Collective and individual mindfulness share an emphasis on an increased attention to
internal and external present-moment phenomena and on approaching the present
moment with an accepting, open, and nonjudgmental attitude. Like individual mind-
fulness, collective mindfulness is as much about what teams do with what they notice as
it is about the act of noticing itself (Weick et al., 1999). A notable distinction,

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6 Medical Care Research and Review

however, is that collective mindfulness is a social process that exists only to the extent
that it is collectively enacted (Levinthal & Rerup, 2006; Vogus & Sutcliffe, 2007b).
We posit that collective mindfulness will provide the nursing team the cognitive
infrastructure that is necessary to develop an increased situational awareness of the work
processes, the safety regulations, and how the combination of the two may poten-tially
lack complementarity. Also, the accepting, open, and nonjudgmental attitude that
characterizes collectively mindful nursing teams is expected to induce nursing teams to
search for structural solutions rather than opting for “quick fixes.” Specifically, collec-
tive mindfulness will enable nursing teams to consider a detailed root-cause analysis of
the occupational safety failures (or signals that may lead to occupational safety failures)
and to come up with structural solutions that incorporate the expertise of every indi-
vidual team member. Such a pattern of behavior is expected to reduce the number of
occupational safety failures through a reduction in work-arounds caused by the lack of
complementarity between work-process design and safety regulations.

Hypothesis 2: Collective mindfulness is related to fewer occupational safety fail-

ures among nurses through a reduction in safety work-arounds.

Method
Participants and Procedure
Data were collected from four general hospitals. The number of beds varied from 217 to
811 and none of the hospitals were university teaching hospitals. We surveyed 580 nurses
in 54 nursing departments with different specializations, including surgery, geriatrics,
emergency medicine, pediatrics, maternity, psychiatry, revalidation, dental care,
oncology, cardiology, gastroenterology, orthopedics, radiography, and polyclin-ics. We
defined a team as a minimum of two nurses operating under the direct supervi-sion of one
head nurse (i.e., minimally, as a three-person work group). Participating nursing
departments had an average of 11 nurses who provided care for an average of 19 patients.
The nurses who participated in the study were, on average, 38 years old (SD = 11), had
worked in the hospital for 14 years (SD = 11), and had worked as a nurse for 15 years
(SD = 10). On average, nurses worked in the hospital for 33 hours per week (SD = 8). A
total of 75% of the nurses were female.
We received permission from the nursing directors in each hospital to conduct our
survey and then presented the purpose of the study to the head nurses to stimulate
participant recruitment. We did not reveal the hypotheses of our study and we guaran-
teed confidentiality. Paper surveys were distributed in large envelopes to each nursing
department, and nurses were asked to deposit the completed surveys in a locked box
placed in the coffee room of each nursing department. Surveys were deposited in sealed
envelopes to assure anonymity. We visited the nursing departments 2 weeks after the
distribution of the surveys to collect the completed surveys.
Data were collected in the nursing departments in two stages. In Stage 1, we col-lected
580 surveys from nurses in four hospitals, a response rate of 70%. We used the

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Dierynck et al. 7

data from these surveys for our multilevel analyses. In Stage 2, 6 months later, we
used the same procedure to collect survey data from the head nurses on the number
of occu-pational safety failures obtaining a 100% response rate. We used the data
from these surveys to assess the reliability of the number of occupational safety
failures the nurses reported in Stage 1. To avoid survey fatigue, the hospital
management did not permit us to distribute the survey to all nurses in Stage 2.
While the use of self-report data has limitations, we found it to be an essential
method of reporting the measures we collected. It is very difficult for individuals to
accurately report on the extent to which another individual may engage in mindful or
work-around behavior, or the extent to which they experience incidents related to
occupational safety. Individuals are not likely to widely articulate that they decided
to work-around an official safety regulation. Relatedly, it would be difficult for
others to ascertain the cause of an individual’s injury, if they noticed it at all.
Following this rationale, we found that self-report data were an appropriate means of
obtaining the data of interest, particularly individual error.

Measures
Individual Mindfulness. We used the Mindful Attention and Awareness Scale
(MAAS) to assess individual mindfulness (Brown & Ryan, 2003). The MAAS
measures the absence of attention and awareness in thoughts, emotions, physical
sensations, and behaviors. Given our focus on predicting workplace behaviors rather
than on individ-ual well-being (Dane, 2011), we chose to include only the behavioral
items of the MAAS and asked respondents to what extent these items reflected their
work-related experiences. Items were measured on a 6-point Likert-type scale
ranging from almost never to nearly always and are thus reverse-scored. The items
are (a) “I could break or spill things because of carelessness, not paying attention, or
thinking of something else”; (b) “I rush through activities without being really
attentive to them”; (c) “I do jobs or tasks automatically, without being aware of what
I’m doing”; (d) “It seems I am running on automatic pilot without much awareness
of what I’m doing”; and (e) “I find myself doing things without paying attention.”
The Cronbach’s alpha value for this measure was .83.

Collective Mindfulness. We used the Safety Organizing Scale to take a safety-specific

measure of collective mindfulness (Vogus & Sutcliffe, 2007b). This scale includes nine
items measured on a 5-point Likert-type scale ranging from not at all to to a very great
extent. Example items include “We spend time identifying activities we do not want to go
wrong” and “When errors happen, we discuss how we could have prevented them.” The
Cronbach’s alpha value for these items was .92. Because we are interested in team levels
of collective mindfulness, we checked whether we could aggregate this measure to the
team level of analysis. Supporting the aggregation of this measure (Bliese, 2000), we
found an average rwg of .92 (Mdn = .92), an ICC(1) of .26 and an ICC(2) of .80, and a
significant amount of between-group variance F(53, 579) = 4.93, p < .01. Please note
that, in this study, collective mindfulness is not defined as the aggregate of individual

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8 Medical Care Research and Review

mindfulness at the group level; instead, it refers to distinct group processes and is
mea-sured at the group level of analysis. Because we are testing a multilevel model,
we sepa-rate the between-subject and between-group effects as distinct sources of
variance in work-arounds.

Work-Arounds. We used a validated four-item scale to measure work-arounds (Hal-

besleben, 2010). Example items include “I bypass safety rules in order to get work
done” and “I follow safety procedures, even if it causes my work to take longer”
(reverse-scored). Items were scored on a 5-point frequency scale from 1 (never) to 5
(everyday). We obtained a Cronbach’s alpha value of .87.

Occupational Safety. We collected occupational safety failures from the nurses by

means of a checklist based on the Bureau of Labor Statistics system and of an
existing survey from the Centers for Disease Control and Prevention (2004), with
some modi-fications to address the specific injuries health care professionals face in
a hospital setting (Halbesleben, 2010; Halbesleben et al., 2013). Items included the
frequency with which nurses experienced “allergic skin reactions,” “bruises,” “back
pain,” “needle sticks,” and “chemical splashes (bodily fluid)” as a result of their
work dur-ing the past 6 months. Over 6 months, nurses experienced an average of 8
incidents (SD = 7.00).
A meta-analysis conducted by Beus, Payne, Bergman, and Arthur (2010) indicates that
self-reports and cross-sectional data can artificially strengthen the relationship between
safety attitudes and safety outcomes. To assess the reliability of our outcome variable, we
asked head nurses to report the number of safety failures 6 months after we collected the
other measures (Mitchell & James, 2001). The correlation between the number of
occupational safety failures reported by the head nurse and the sum of the number of
occupational safety failures reported by the members of the nursing team is .40 (p < .05,
N = 54 teams). Although this statistic does not substitute for lon-gitudinal data, it gives us
some confidence that our outcome measure is reliable. Furthermore, it corroborates our
earlier argument that self-reported data may be more accurate for capturing this
information since it may be difficult for others to accurately assess another person’s
experience related to safety and error reporting. Also note that each theoretical construct
in our multilevel analyses requires individual-level data, making it impossible to use the
number of occupational safety failures reported by the head nurses in the survey
administered in Stage 2.

ControlVariables. We controlled for characteristics of the nurses, the nursing teams, and
the hospitals to account for nonspecific effects. First, we controlled for characteristics of
the nurse such as age, tenure in the hospital, and tenure in the nursing department.
Second, we included the average number of patients cared for by the nursing teams, as
occupational safety may be a function of nurse workload (Katz-Navon et al., 2005).
Third, we measured the average complexity of patient conditions in the work unit using
six items (Hofmann & Mark, 2006) to control for the fact that occupational safety may
also be a function of more complex patient conditions. An example item

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Dierynck et al. 9

from this measure is “How many patients on your unit have complex problems that
are not well understood?” These items were measured on a 5-point Likert-type scale
rang-ing from a few (<20%) to most (>80%). Fourth, we controlled for potential
differences between the hospitals by controlling for hospital size, which is measured
by the total number of beds (Katz-Navon et al., 2005). We derived each nurse’s
hospital affiliation from the data collection. We found that adding these controls did
not meaningfully change our results. Therefore, following the recommendations of
Becker (2005), we omitted these variables from subsequent analyses.

Analyses
We analyzed the data using structural equation modeling in two steps (McDonald &
Ho, 2002). First, we conducted a confirmatory factor analysis on our measurement
model. The measurement model showed a good fit to the data (Hu & Bentler, 1998,
1999): χ²(168) = 510.82 (p = .00), standardized root mean square residual = .05, root
mean square error of approximation = .06, and comparative fit index = .95. When we
alternately constrained each pairwise factor to unity, we found that, in each case,
con-straining the factor correlation significantly worsened the model (p < .05).
Because multilevel structural equation models are too parameter intensive for our
data, we proceeded with testing the structural relationships using aggregated
measures in a multilevel path model (Grizzle, Zablah, Brown, Mowen, & Lee, 2009).
The results obtained using the multilevel path model are similar to those obtained
through hierar-chical linear modeling (Grizzle et al., 2009).
To assess our hypothesized cross-level model, we followed the procedures described
by Hofmann (1997) and Hofmann, Griffin, and Gavin (2000) and adopted by Walumbwa,
Wang, Weng, Schaubroeck, and Avolio (2010). Specifically, we first tested the main
effects in our model. In hierarchical linear modeling terminology, this consists of an
intercept-as-outcome model. We established the mediating effects by testing alternative
models that specify a direct link between individual mindfulness, collective mindfulness,
and occupational safety (James, Mulaik, & Brett, 2006; Preacher, Zyphur, & Zhang,
2011). These alternative models indicate whether a resid-ual direct effect remains after
work-arounds are included in the model.
Finally, because the teams in our data set are further nested within organizations,
we accounted for nonindependence in our data at the organizational level by
including the “type=COMPLEX” command in Mplus. This command corrects
standard errors and the chi-square test of model fit for nonindependence of
observations (Satorra, 2000).

Results
Table 1 shows the means, standard deviations, and correlation coefficients for the study
variables. The correlations are in the direction consistent with our hypotheses.
Specifically, the correlation between collective mindfulness and work-arounds and
between individual mindfulness and work-arounds are both significantly negative (r =

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10 Medical Care Research and Review
Table 1. Means, Standard Deviations, and Intercorrelations Among Study Variables.

M SD 1 2 3 4
1 Individual mindfulness 4.38 0.57 .83  
2 Collective mindfulness 3.60 0.73 .14** .92  
3 Work-arounds 3.72 0.85 −.30** −.32** .87  
4 Occupational safety failures 7.86 7.00 −.14** .08 .20** —

Note. Reliability estimates for scales are presented on the diagonal.

*p < .10. **p < .05.

−.30, p < .05, for individual mindfulness; r = −.32, p < .05, for collective
mindfulness). The correlation between work-arounds and the number of occupational
safety failures is significantly positive (r = .20, p < .05). To assess our hypothesized
cross-level model, we first examined the degree of between-group variance for work-
arounds and occupational safety failures. Results for a null model showed that 22%
of the variance in work-arounds and 25% of the variance in safety failures was
between-group variance.
When assessing group-level effects, we applied grand mean centering to partial
out variance in individual-level variables (e.g., individual mindfulness; Hofmann &
Gavin, 1998). Figure 1 shows the standardized parameter estimates for our hypothe-
sized model. Both individual mindfulness (ŷ = −.27, p < .05) and collective mindful-
ness (ŷ = −.62, p < .05) were significantly negatively related to safety work-arounds,
and safety work-arounds further predicted the number of occupational safety failures
(ŷ = .13, p < .05).
Next, we tested our mediation hypotheses by specifying a direct effect for collec-
tive mindfulness (ŷ = −.21, p = .21) and individual mindfulness (ŷ = .01, p = .88) on
occupational safety failures. To test the cross-level mediation effect, we followed the
recommendations of Zhang, Zyphur, and Preacher (2009), who argued that cross-
level mediation effects may be confounded if one looks at between-subject, rather
than between-group, effects as mediators. These results confirm that the effects of
individ-ual and collective mindfulness operate through safety work-arounds.

Discussion
Individual and team cognition are important in complex and uncertain environments such
as hospitals. Indeed, reliability often results from stable processes of cognition that help
individuals and teams develop a detailed understanding of the situation (Weick et al.,
1999). In this study, we seek to address the lack of research concerning the role of
cognition for improving occupational safety in hospitals by examining how individual
and collective mindfulness are related to occupational safety in hospitals. Work-arounds,
defined as the intentional bypassing of existing safety regulations, have a pivotal role in
our theoretical model as we posit that individual and collective mindfulness influence
occupational safety through a reduction in work-arounds. We

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Dierynck et al. 11

Figure 1. Hypothesized model.

**p < .05.

expect individual mindfulness to reduce the depletion of nurses’ motivational

resources caused by worrying about the future consequences of adhering to time-
consuming safety regulations. As such, nurses have more motivational resources
available for adhering to the safety regulations, leading to less work-arounds and
more occupational safety.
We posit that collective mindfulness will provide the nursing team with a
cognitive infrastructure that enables detailed root cause analyses of occupational
safety failures and the development of structural solutions for occupational safety
failures. Thus, nursing teams that are more collectively mindful should engage less in
working around existing safety regulations, leading to a higher degree of
occupational safety. The results of a multilevel analysis of survey responses of 580
nurses support the hypoth-esized relationships between individual and collective
mindfulness, work-around, and occupational safety.
This study contributes to research and practice in two ways. First, by providing
empirical support for the positive effects of mindfulness on occupational safety in
hospitals, this study contributes to a better understanding of the role of cognition in
occupational safety. By using work-arounds to explain the relationship between mind-
fulness and occupational safety failures, this study also helps clarify the underlying
mechanism that drives the effect of mindfulness. While the pioneering work of Vogus and
Sutcliffe (2007a) has already documented that collective mindfulness reduces medication
errors, it does not address the unique underlying processes through which collective
mindfulness influences safety outcomes. As documenting these underlying mechanisms
is a next step toward better understanding the effects of mindfulness, our study advances
knowledge about the role of mindfulness in the workplace and has the potential to change
the way in which occupational safety is managed in hospitals.
Second, to our knowledge, this study is the first to consider individual and collec-tive
mindfulness simultaneously and to investigate the unique variance accounted for by each
construct in predicting work-arounds and occupational safety. Although some

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12 Medical Care Research and Review

researchers have advocated for viewing occupational safety as a function of individ-

ual-level and team-level antecedents, studies that focus on both are scarce (Christian
et al., 2009). Our study fills this gap and provides an empirical toolkit that should
stimulate further research in this area.

Managerial Implications
This study provides guidance on how hospital managers can improve occupational safety.
We believe that such guidance is important as occupational safety plays a pivotal role in
the efficient and effective functioning of hospitals. For example, hospitals often develop
performance indicators related to occupational safety and use them for the evaluation of
nurse managers because nursing turnover and/or exit from the profession are clear
outcomes if occupational safety is ignored or downplayed. In other words, the immense
costs of recruiting and training new nurses can be obviated, at least in part, by improving
nurses’ occupational safety. Also, a lack of occupational safety often results in negative
media attention and reputational damage for the health care organization.
We believe that our results suggest two implications for hospital managers. First,
hospital managers should consider emphasizing mindfulness when designing policies
for improving occupational safety. A natural response to occupational safety failures
is to implement new safety regulations (Hannan & Freeman, 1984). Although safety
regulations are necessary to ensure reliability, the effectiveness of these safety
regula-tions is reduced when employees work around them. This study shows that
individual and collective mindfulness can reduce the tendency to work around a
safety regula-tion, leading to a safer work environment. Note that we do not suggest
that hospitals should reduce the emphasis on safety regulations. Instead, we argue
that hospitals may benefit from simultaneously focusing on mindfulness to increase
the effectiveness of implementing safety regulations.
Second, our study suggests that hospital managers should focus on improving both
individual and collective mindfulness rather than making a choice between the two. One
potential way to increase individual mindfulness is by offering mindfulness train-ing, a
practice already observed in other organizations tasked with delivering an error-free
service in dynamic, complex, and time-pressured conditions (such as aircraft carrier flight
desks and nuclear power control rooms). Collective mindfulness can be improved by
implementing mindfulness-inducing HR practices. Positive employee relations and
emphasizing training have been shown to induce collective mindfulness as they stimulate
sensitivity to operations and commitment to resilience, which are two of the five
underlying processes of collective mindfulness (Vogus & Welbourne, 2003). Creating an
environment where employees feel safe to speak up also has the potential to induce more
collective mindfulness (Edmondson, 1999). Previous research suggests that particular
leadership styles, such as authentic leadership, and particular behavioral patterns in the
leader’s behavior, such as word-deed alignment, help develop an environment where
employees feel safe to speak up (Leroy et al., 2012).
Finally, recent research suggests that collective mindfulness is more likely to
emerge when team members experience emotional ambivalence and prosocial

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Dierynck et al. 13

motivation (Vogus, Rothman, Sutcliffe, & Weick, 2014). Although empirical

evidence concerning the relationship between emotional ambivalence, prosocial
motivation, and collective mindfulness is lacking, hospitals can incorporate these
insights into their employee selection procedures. Importantly, the different
approaches outlined in this article to stimulate collective mindfulness also
complement lean and other quality improvements initiatives in hospitals.

Limitations and Future Research

A brief mention of some limitations of this study should be made to place our results in
perspective. First, our data are cross-sectional and derived from a single source: hospital
nurses. We therefore must be careful with the conclusions we draw regarding the
causality of our arguments. An alternative explanation for our results could be that nurses
who have experienced an occupational safety failure are more likely to say that they or
their team should be more mindful. Our data does not allow for the disentan-glement of
this alternative explanation from the theoretically grounded explanation we have
developed and tested in this study. That said, the effect of experiencing an occu-pational
safety failure on individual and collective mindfulness is an unexplored research area and
deserves more attention in future research.
We must also be careful with the conclusions we draw regarding the strength of
our cross-sectional findings (Podsakoff, MacKenzie, Lee, & Podsakoff, 2003).
Although the common method bias may have biased these relationships, it would
likely have influenced all relationships in the same way and therefore would not
influence our test of the mediation hypotheses. Longitudinal research, in any case,
may help overcome these issues.
Second, research is needed to determine the extent to which the relationships we
document are generalizable to other health care settings. Such generalization rests on
the assumption that the use of safety regulations to enhance occupational safety and
the prevalence of safety work-arounds are not unique to hospital settings. Although
empirical evidence supports this assumption (see Christian et al., 2009, for an over-
view), establishing the boundary conditions of our argumentation by investigating
the role of individual and collective mindfulness in other health care settings, such as
nursing homes, is an important next step that should be taken.
Third, in our study, we measured individual and collective mindfulness and used
differences between individuals and teams to investigate the effects of individual and
collective mindfulness. Our decision to measure differences in mindfulness rather
than to induce differences in mindfulness between individuals and teams by
manipulating mindfulness with an intervention is in line with the majority of
research in this domain. Furthermore, in previous research, measuring mindfulness
differences yields similar outcomes as those derived from inducing differences in
mindfulness (Chiesa & Serretti, 2009).
On the other hand, improving nurses’ occupational safety by focusing on mindful-
ness may occur via mindfulness training at both the individual and team level. Future
research should thus examine whether mindfulness training or short inductions can

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14 Medical Care Research and Review

increase occupational safety through a reduction in safety work-arounds. Given that

the typical 8-week-long mindfulness training (e.g., Kabat-Zinn, 2002) is not always
feasible in health care contexts, future research should also study whether and how
shorter mindfulness inductions (Koole, Govorun, Cheng, & Gallucci, 2009) enhance
performance outcomes.
Finally, the relationship between individual mindfulness and collective mindful-ness
should be further explored. In this study, we explicitly chose to study both con-cepts at
different levels of analysis. We highlighted similarities as well as differences in both
constructs and demonstrated the importance of including both when predicting work-
arounds. Future research needs to clarify how both may be interrelated.

Conclusion
Previous research has already documented several benefits of mindfulness. Individual
mindfulness has been shown to enhance positive outcomes in several important life
domains, including mental health, physical health, behavioral regulation, and interper-
sonal behavior (see Brown et al., 2007, for an overview). The performance effects of
collective mindfulness have also begun to emerge (Rerup, 2009; Vogus & Sutcliffe,
2007a). In this study, we examined the effects of individual mindfulness and collective
mindfulness on occupational safety in hospitals and clarified how each type of mind-
fulness is linked to nurses’ occupational safety.
Overall, this study emphasizes the importance of mindfulness as one potential way to
reduce nurses’ well-documented tendency to work around occupational safety regula-
tions. Unpacking the roles of individual mindfulness and collective mindfulness in
ensuring occupational safety may further advance our knowledge of how to create safer
workplaces. At a broader level, this study speaks to the debate about the efficacy of
introducing safety regulations to create safer workplaces (Lucian Leape Institute, 2013).

Acknowledgments
We are indebted to Jonathon Halbesleben, Kathleen Sutcliffe, and Timothy Vogus for helpful
comments on earlier versions of this article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of
this article.

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