Building safer cultures, and a stronger nursing workforce
By Tejal Gandhi, MD, Chief Safety and Transformation Officer, Press Ganey
Healthcare organizations have traditionally viewed the challenges of the nursing workforce and patient safety through separate lenses. But the data indicates they’re far more connected than many realize. Staffing, engagement, retention, and safety are deeply intertwined, shaped by the conditions nurses experience every day. Strong nursing cultures and strong safety cultures are often one and the same.
Understanding this relationship has important implications for all healthcare leaders. In many organizations, workforce challenges are addressed through staffing initiatives, and safety challenges through separate quality and risk programs. But the highest-performing organizations recognize that both are reflections of the same culture. When nurses feel supported, heard, and empowered to do their best work, engagement improves. As a result, safety does too. And when safety improves, trust deepens—trust between patients and their caregivers, between the front lines and their leaders, and across the organization.
A strong safety cultures wins twice
Safety culture is one of the most influential forces shaping the nursing workforce. It drives engagement among registered nurses (RNs) and advanced practice providers (APPs), while strengthening the trust, communication, and collaboration that high-performing teams depend on. Just as importantly, it supports the reliability of the clinical and operational processes that underpin safe, effective, exceptional care.
These same cultural attributes also help build and sustain what many organizations now recognize as a critical competitive advantage: social capital—the relationships and shared commitment that help healthcare workers feel heard, supported, and part of something bigger than their individual role. When social capital is strong, nurses are more likely to feel psychologically safe, speak up about concerns, stay engaged, and remain committed to their organization.
Social capital serves as the connective tissue between workforce engagement, safety culture, and care quality. Leaders who are visible and responsive, teams that communicate openly, and environments where employees can raise the red flag without fear of retaliation help create the conditions for both workforce resilience and high reliability.
But the impact of safety culture doesn’t begin and end within the four walls. Hospitals in the top quartile for RN perceptions of safety are nearly 6x more likely to achieve top-quartile patient experience scores for “Rate Hospital 0–10.” This relationship highlights a powerful principle of healthcare performance: The environments in which nurses thrive are often the very environments that enable safer, more reliable care.
Safety protocols can’t compensate for silence
Healthcare organizations have made significant investments addressing physical safety. Their efforts have, in many ways, paid off. But in our relentless pursuit of Zero Harm 24/7, there’s an element just as important as physical safety, though perhaps less visible: psychological safety.
Psychological safety lays the groundwork for continuous learning and safety improvement. It empowers nurses to raise concerns before they escalate into more serious problems, report near misses without fear of retribution, challenge assumptions, and ask difficult questions that ultimately lead to better decisions and safer outcomes for patients and caregivers alike.
Without psychological safety, even the most well-designed protocols and processes become vulnerable and begin to show cracks. Safety depends not only on the systems organizations build, but also on the willingness of people to use their voices—and the confidence to do so—when something doesn’t seem quite right.
Workplace violence remains a significant threat. While reported rates of violence against nurses have increased in recent years (from 2.04 per 100 full-time equivalents in 2019 to 2.57 in 2025), this may reflect greater willingness to report incidents, rather than a true increase in occurrence. Regardless, the prevalence of violence is unacceptable.
Beyond the immediate physical and emotional toll, violence in care settings undermines both engagement and safety culture—whether employees experience it directly or witness it. Those exposed to violence report lower engagement and weaker perceptions of safety culture, with measurable consequences for workforce stability and care delivery. Healthcare workers who frequently experience violence from patients report engagement scores of just 3.58, compared with 4.14 among those who never experience violence. The burden is particularly pronounced on the night shift, where employees are 3x more likely to frequently witness violence and four times more likely to frequently experience violence from patients or family members.
What happens when the work follows the workforce home?
One of the most critical yet overlooked threats to workforce sustainability is the inability to decompress.
Today, 25% of RNs and 37% of APPs struggle to mentally disconnect from work. That statistic is serious cause for concern, as decompression affects more than employee resilience and well-being. When nurses remain burdened by the cognitive and emotional demands of care long after their shift ends, safety and clinical performance suffer, while burnout and turnover risk rises.
Addressing this challenge requires leaders to look beyond individual resilience and focus on the design of work itself. Unreliable staffing, burdensome documentation processes, inefficient workflows, and constant interruptions introduce friction that increases cognitive load and makes it harder for nurses to decompress and disconnect. When clinicians regularly feel their work is unfinished, the mental and emotional demands of care often follow them home.
The most effective organizations treat decompression as a system design challenge, not a personal responsibility. By reducing operational friction and creating opportunities for teams to close loops, debrief, and support one another, leaders help nurses recover between shifts. The question is no longer whether nurses are resilient enough to handle the work. It’s whether doing that work day after day is sustainable.
Safety culture is only as strong as its weakest link
Not every clinician experiences safety culture in the same way. Role, tenure, and shift all influence how work is experienced—and, in turn, how safe people feel speaking up, reporting concerns, and contributing to improvement efforts. Advanced practice providers (APPs), early-career nurses, and night-shift teams each face distinct challenges, from administrative burden and limited access to leadership to fewer opportunities for connection, mentorship, and recovery.
One of the most pronounced gaps exists between day- and night-shift nurses. Night-shift RNs, who experience higher rates of violence, also report lower perceptions of safety culture, particularly in areas related to prevention, reporting, and organizational pride.
This is an important reminder for healthcare leaders: Safety culture cannot be assumed to exist uniformly. It must be intentionally cultivated across every shift, unit, and role. One-size-fits-all approaches rarely address the realities clinicians face in their day-to-day work. Building a strong safety culture requires understanding where gaps exist and designing solutions that reflect people’s unique needs and expectations.
4 ways healthcare leaders can strengthen safety culture
A strong safety culture reflects the choices leaders make every day. How work is designed. How teams are supported. How trust is developed. When those elements are aligned, caregivers are better able to do their best work. In turn, patients receive the best care, and organizations achieve the best possible outcomes.
While every organization’s path is different, a few high-impact strategies consistently distinguish high-performing organizations.
- Give nurse managers the capacity to lead. Nurse managers have a significant influence on culture and safety. When they oversee too many direct reports, they have less time to support staff, coach teams, and address concerns.
- Show up on the front line. Safety cultures are stronger when leaders regularly spend time in care environments where they can listen to staff. Equally important is the follow-through—i.e., letting nurses know that they responded to what they heard, and how.
- Normalize speaking up. Nurses should feel comfortable raising concerns, reporting near misses, and questioning processes without fear of blame. These conversations are essential to learning and improvement.
- Never overlook or underestimate what the workforce is telling you. Workforce feedback is one of your most valuable resources. It can reveal emerging risks before they affect retention, patient experience, or outcomes. Leaders who act on these insights are often able to address challenges before they become major problems.
The more I study high-performing healthcare organizations, the more convinced I am of one truth that has consistently guided my thinking: Safety is the chassis. It’s the very structure supporting care delivery and experience, patient and workforce trust, and every outcome that follows. And when healthcare leaders treat safety as a strategic investment rather than a compliance requirement, people and performance alike reap the rewards.
Learn more about how safety culture shapes both nurse and patient outcomes in our “State of nursing 2026” report. Or reach out to a member of our team for a deeper dive.