It is important to clarify what is meant by the ‘internal’ and ‘external’ environments, for it is within these domains that threats to well-being and safety take place. Although both have potential dangers for human life and well-being, they are discretely different, both in the likely risks to safety and in the way in which threats may be managed.

For the purposes of this chapter, the internal environment can be described as the functions and workings of the human body. The body’s ability to maintain a homeostatic (stable) internal environment is essential to well-being (see Ch. 7). The essential consideration of the internal environment in relation to health and safety is concerned with its interaction with the external environment and the effects which may result. The external environment is the world surrounding the human body. In order to function, the human body has essential requirements, which must be met externally. Conversely, the actions of individuals can influence the safety and ambience of the external environment for all who live in it. Both environments are highly dependent upon one another for their own maintenance.

There are many ways in which individuals strive to understand risks in their daily lives and many factors influencing how they may act in the light of such perceptions (Bloor 1995). Fallowfield (1990) suggests that quality of life, and therefore ultimately perceived health and well-being, is directly related to the quality of the environment in which life exists. The environment must also satisfy physiological, psychological and sociological needs. Fallowfield (1990) further identifies four areas where the perception of life quality is paramount:

These areas are useful for exploring factors associated with determining life quality. However, it should be remembered that the way you view something may be very different from the way another person perceives it. Culture, social class, gender, age, level of education and emotional state should be acknowledged. Toxic effects from drugs and general level of health are also important. Finally, there may be differences in the perception of priorities between patients and their carers. A knowledge of these differences can be critical in facilitating the provision of appropriate care.

Stress can alter an individual’s perceived environment, which can ultimately become hazardous. The main issues associated with psychological stress and its effects on the internal environment are addressed elsewhere (see Ch. 9). However, it is important to consider how the effects of stress on an individual can impact on his or her immediate external environment.

Risk perception is different from the knowledge of a danger, as it does not necessarily cause people to worry. Risk perception may result from the personal orientations that guide an individual to make commitments consistent with one specific political culture and inconsistent with others. At the same time cultures may select those individuals who support their way of life. Individuals may choose what to fear in supporting their preferred way of life (Royal Society Study Group 1992). For example, a religious sect propounding a particular set of beliefs may attract new members who are sympathetic to the views of that sect. Gabe (1995) identifies that in this sense risk cannot be objectively ‘measured’, but must be viewed as a social construct. This draws from the original anthropological work by Douglas (1966), which addressed questions about why different cultures select different risks for particular attention using beliefs to rationalize behaviour. Given that such interpretations of risk perception are valid, then points of cultural difference are extremely important in nursing. If a patient has different social expectations and selects different risks from the nurse’s social expectation then a true assessment could be difficult and treatment could fail to meet the expectations of both parties. There may even be open conflict between the patient and health professional. For instance, Jehovah’s Witnesses can present a challenge because they may refuse to receive blood transfusions. Where patients are severely ill and unable to give informed consent to treatment or where children require urgent blood transfusion, nurses may then face moral dilemmas in respecting the cultural beliefs of such individuals while acting in their best interest to maintain their safety.

Finally, individuals may react differently in different environments. A perception of risk and a knowledge of danger are important in the care setting because patients may rely on the nurse to protect them (Simpson 1991). Those who are particularly vulnerable include:

Within the hospital setting most patients are away from their known environment and are therefore unable to perceive risks in what amounts to an ‘alien’ environment. It is the responsibility of the nurse to ensure that individuals are aware of hazards wherever possible and are protected by either their own action or action on their behalf by the nurse. The nurse’s role is to ensure the safety of the environment by assessing the potential risks and facilitating action for change.

Risk – the possibility of injury or loss – must be in the minds of all who deliver health care, in every clinical episode and in the planning of all healthcare delivery. The roots of risk management lie in risk assessment and implementation of ensuing preventative action and in the reporting, analysis, investigation and prevention-planning of incidents. Therefore, there are two aspects to risk management: one is forward looking, trying to identify issues and circumstances with the potential to go wrong, and act before they do go wrong. The other is backward looking, trying to learn from incidents by thoroughly investigating the causes and aiming to prevent recurrence.

A key principle in both the To Err is Human and the Organisation with a Memory reports was that when things do go wrong, the most likely and accurate underlying causes are related to ‘systems failures’ rather than the failures of individuals. It is of course possible that incidents where safety has been compromised are due to reckless or thoughtless actions by individuals, but evidence from research into ‘human factors’ (the study of all aspects of the way humans relate to the world around them) predominantly points to individuals being as much victims of failings within the design of systems and processes than the causes of such failings. The National Patient Safety Agency (NPSA) in the UK, which was established as a result of the Organisation with a Memory report, promotes the principle of systems failures being at the heart of most incidents in much of its work.

So far, there has been an emphasis upon individual responsibility within personal environments, with some discussion about people’s behaviour when interacting within the healthcare environment. It is, however, important to recognize that the organization has influence in creating a healthy environment. According to Cox & Griffiths (1996: 128) a ‘safe’ environment might be relatively easy to define, but perceptions of a ‘healthy’ work environment are usually narrowly focused on physical threats to health. These authors argue that healthy work can be defined as ‘work that does not threaten but which helps maintain and enhance physical, psychological and social well-being’.

A ‘hazard’ has been defined as an event or situation that has the potential to cause harm (Cox & Griffiths 1996). Besides physical hazards referred to in the previous section, the International Labour Organization (1986) has defined psychosocial hazards arising from interactions between job content, work, organizational, management and environmental conditions, and the employee’s competencies and needs. Those interactions that can be defined as hazardous influence the health of employees through their ‘perceptions’ and ‘experiences’ of these conditions (International Labour Organization, 1986 and Cox et al., 1995). Exposure to psychosocial hazards in particular is often chronic and cumulative, except when a particular acute, traumatic incident occurs. Table 3.2 outlines the common psychosocial hazards associated with the work environment and the conditions that define the potential level of hazard for the individual employee.

The synergistic nature of the physical and psychosocial hazard in the work environment is also important. Interactions can occur between the different types of hazard and their consequent effects on the health of the individual (Levi 1984). Stress in the workplace, from whatever cause, may inadvertently lead to risk taking behaviour by the individual worker.

When dealing with safety issues in the workplace environment, there have been three common approaches (Landy 1989):