Importance of Topic to Practice
Mitigating the risk of food contamination is critical for food service operations, but particularly for health care organizations where food is served to individuals who could experience the symptoms of foodborne illness more severely than others, including seniors, pregnant individuals and those with weakened immune systems (1,2). Food must be safe to be nutritious and it must be safe to prevent malnutrition, making food safety paramount to patient safety (3). The WHO suggests that food safety, nutrition and food security are intricately connected (4). Food safety includes preventing pathogen, prion, chemical and physical contamination as well as allergen contamination (5). Additionally, in health care, food safety and resident/patient/customer safety are entwined when providing the foods and fluids prescribed to mitigate the risks of choking and aspiration (6) and the consequences of unsafe food handling on immunocompromised individuals (7).
Food safety has been traditionally founded on techno-managerial functions found in a food safety management system, which is often comprised of managerial and administrative structures and processes, such as Hazard Analysis and Critical Control Point (HACCP) that supports design, delivery, maintenance, evaluation and continuous improvement (8). The techno approach involves complying with regulations, controlling hazards and maintaining records (3), whereas the managerial approach focuses on quality improvement and assurance (9). Recently, there has been a shift to a more holistic approach that includes the human element, which focuses on culture.
Dietitians and nutrition managers strive to provide high quality, safe food to residents/patients/customers. To foster compliance with food safety regulations and best practices with the aim of mitigating risks, dietitians and nutrition managers should cultivate a positive food safety culture in health care facilities, and more specifically, food service operations.
Topic Overview
Griffith, Lively and Clayton define food safety culture as the “shared attitudes, beliefs and values towards food safety behaviours that are routinely demonstrated in food handling organizations” (10). A positive food safety culture supports the techno-managerial approach by encouraging food handlers to hold each other accountable, leaders to model intended behaviours, and all employees to value doing the right thing.
Food safety climate, a component of food safety culture, provides a snapshot of food safety at one point in time (11). Food safety climate is temporary and is comprised of employees’ shared perceptions of leadership, risk awareness, communication, commitment and resources (9). Food safety culture is the interaction between food safety climate, or the human element, and the techno-managerial approach, or the food safety management system.
The Food Safety Culture Continuum
Each food service operation has a food safety culture that lies on a continuum from negative to positive (11). Through fostering a positive food safety culture, food handlers make decisions based on their values and beliefs rather than on rules or procedures. Consequentially, food handlers have enhanced motivation to follow procedures with consistency and accuracy, to hold each other accountable, and to speak up when food safety is compromised. A negative food safety culture develops when food safety is not a priority, resulting in poor compliance with food safety regulations, principles and best practices, which increases the risk of serving unsafe food. Measuring activities is important to assess compliance with safety management systems, identify strengths and risks, increase food safety awareness, benchmark, and to determine quality improvement initiatives. Given that it is challenging to measure food safety culture, food safety climate is often measured instead.
How is food safety culture created or influenced?
Clayton and Griffith suggest the formation of a negative food safety culture emerges from misguided or inappropriate management and that food handlers are more influenced by their peers than their managers (12). In contrast, a positive food safety culture is fostered by managers who create a food safety vision flowing from the organization’s vision or strategic directions, set and communicate performance expectations, allocate resources to support food safety, and motivate employees to follow food safety processes and procedures (12). Managers also have a role in modelling specific behaviours, making decisions that prioritize food safety, and being seen as prioritizing food safety (12). Thus, food safety culture is hinged on leaders who set the tone, create and foster an environment conducive to learning food safety behaviors, and practice these behaviours (13).
How is a positive food safety culture created?
There is no standard approach to creating a food safety culture. Moreover, most available tools do not assess the deeper layers of culture. The literature identifies the following as determinants of a strong and effective food safety culture (13,14):
- Develop leaders’ awareness of their roles and responsibilities in fostering a culture that is supported by policy.
- Provide food handlers and managers with specific education and training to promote knowledge, attitude, behaviour and values that are essential to a positive food safety culture. This includes awareness of potential hazards and their associated risks.
- Enhance communication about food safety and provide feedback to food handlers, focusing on sharing well-defined food safety messages across the organization.
- Implement an effective food safety management system. This includes documenting specific food safety performance expectations and recognizing individual and collective contributions.
- Screen employees for a strong work ethic, sense of responsibility, knowledge of food safety and the ability to work collaboratively. Hold all employees responsible for their level of food safety performance. Engage food handlers to foster commitment and focus their efforts on achieving food safety goals. Consider developing a system of rewards and sanctions related to food safety performance.
- Build or modify the physical environment to support positive food safety behaviours. Keep abreast of industry trends, including emerging food safety risks, reports of work incidents, changes to legislation and new technologies.
- Assess food safety performance measures against standards. Apply assessment tools that become available and more widely implemented.
Building on these strategies, researchers suggest that establishing and communicating expectations is critical to creating a positive food safety culture (13,15,16). Individuals should understand how their roles contribute to the organization’s values and how their roles support the provision of safe food (15,16). Messages used to communicate food safety expectations should be simple, clear, risk-based, relevant and achievable (13,15,16). These messages can be disseminated through departmental policies, procedures, signs, huddles, formal meetings, performance reviews, managerial rounding, orientation and training (14,15). Work pressure should be managed by avoiding a “culture of punishment” that disengages employees (13). A positive food safety culture is achieved when food handlers do the right thing because they are committed to the safety of residents/patients/customers; this is important given each task a food handler completes presents an opportunity to compromise food safety (15).
Why is it important to cultivate a positive food safety culture?
The following examples describe the impact of a poor food safety culture and/or symptoms of a compromised food safety culture, and provide the impetus for fostering positive food safety cultures:
- Health inspectors in a mid-sized Canadian city addressed an anonymous complaint regarding a cook who had posted a photo on the Internet showing himself holding a large pan of rice crispies squares to his open mouth (17). The complainant alleged that the squares were to be served to residents. When asked by an inspector about the photo, the cook stated he followed the directions of HACCP and his food handlers’ course was renewed routinely. When asked if his actions would prevent adulteration, contamination and foodborne illness, when he picked up the rice crispies squares with his hands and held it to his mouth, the cook said no.
- In 2012, beef processed at a Canadian food plant was found to be contaminated with E. coli O157:H7, which led to 18 illnesses and about 4,000 tonnes of beef and beef products recalled from Canadian, American and international markets (18). The beef was disposed of in landfills. Food safety regulations were not followed with the full knowledge of the plant leaders and the Canadian Food Inspection Agency (CFIA) inspectors. One of the key recommendations arising from an independent review of the event was to develop a strong food safety culture within the processing plant, which would be “adopted by both plant and CFIA staff – at all levels”.
- In August 2008, a listeriosis outbreak related to the consumption of meat products in Canada resulted in 22 deaths (19). Factors contributing to the outbreak included the failure of leaders to monitor trends that indicated the recurring presence of Listeria and middle managers withholding information from senior leaders and government inspectors. In a 2009 report, the independent investigator stated “I am calling for swift and significant action in key areas that are critical to food safety – the culture of food processing companies”.
- Authors of the U.K.’s 2021 to 2022 Annual Food Safety Report describe the use of root cause analyses for identifying activities contributing to food contamination (20). For allergen and foreign body contamination,10% of incidents involved procedures not being followed and 8% involved training.
- In 2020, the British NHS issued an alert regarding incidents of food allergens in the food of patients with known food allergies (21). Some of these incidents were due to patients’ allergies not being communicated to food service staff, while others were attributed to training and competency of food service and clinical staff.
How can a food safety culture be assessed?
Researchers offer many types of assessment tools (9,14,22); however, a practical assessment tool applicable to hospitals, long-term care facilities or hospitality food service operations is currently not available. More research is needed to assess the validity of food safety culture assessment tools (13).
Resources for Professionals
References
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- Al-Akash H, Abu Arrah A, Bhatti F, Maabreh R, Abu Arrah R. The effect of food safety training program on food safety knowledge and practices in hotels' and hospitals' food services. Ital J Food Saf. 2022 Feb 22;11(1):9914. doi: 10.4081/ijfs.2022.9914. PMID: 35284344; PMCID: PMC8883829. Abstract available from: https://pubmed.ncbi.nlm.nih.gov/35284344/
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- Johnson M, Tennant B, Newsome J. Food Safety Culture Systematic Literature Review. Food and Drug Administration. 2022. Available from: https://www.fda.gov/media/163588/download
- Zanin L, Stedefeldt E, Luning P. The evolvement of food safety culture assessment: A mixed-methods systematic review. Trends in Food Science & Technology. 2021 118:125-142. DOI 10.1016/j.tifs.2021.08.013. Available from: https://www.sciencedirect.com/science/article/abs/pii/S0924224421005008
- Global Food Safety Initiative. A culture of food safety, a position paper from the Global Food Safety Initiative. 2018. Available from https://mygfsi.com/wp-content/uploads/2019/09/GFSI-Food-Safety-Culture-Summary.pdf
- Yiannas F. Food Safety Culture: Creating a Behaviour-based Food Safety Management System. New York: Springer Science+Business Media: 2009 p. 26, 81, 82. ISBN 1441925007.
- Ministry of Health and Long-Term Care. Inspection Report under the Long-Term Care Homes Act, 2007. 2019. Available from: http://publicreporting.ltchomes.net/en-ca/File.aspx?RecID=22204&FacilityID=20143
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- Government of Canada. Report of the independent investigator into the 2008 listeriosis outbreak. 2009. Available from: https://www.cmc-cvc.com/sites/default/files/files/ListeriaIndependentInvestigatorReport_July212009.pdf
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