Second-order problem solving:Nurses'perspectives on learning from.near misses

护士的二级解决问题行为:从接近失误中学习

Objectives:Near misses happen more frequently than actual errors,and highlight system vulnerabilities without causing any harm,thus provide a safe space for organizational learning.Second-order problem solving behavior offers a new perspective to better understand how nurses promote learning from near misses to improve organizational outcomes.This study aimed to explore frontline nurses’perspectives on using second-order problem solving behavior in learning from near misses to improve patient safety.Methods:A qualitative exploratory study design was employed.This study was conducted in three tertiary hospitals in east China from June to November 2015.Purposive sampling was used to recruit 19 frontline nurses.Semi-structured interviews and a qualitative directed content analysis was undertaken using Crossan’s 4I Framework of Organizational Learning as a coding framework.Results:Second-order problem solving behavior,based on the 4I Framework of Organizational Learning,was referred to as being a leader in exposing near misses,pushing forward the cause analysis within limited capacity,balancing the active and passive role during improvement project,and promoting the continuous improvement with passion while feeling low-powered.Conclusions:4I Framework of Organizational Learning can be an underlying guide to enrich frontline nurses’role in promoting organizations to learn from near misses.In this study,nurses displayed their pivotal role in organizational learning from near misses by using second-order problem solving.However,additional knowledge,skills,and support are needed to maximize the application of second-order problem solving behavior when near misses are recognized.

目的接近失误比实际差错发生更为频繁,且在未造成任何伤害的情况下突显了系统漏洞,这为组织学习提供了安全空间。二级问题解决行为提供了一个新的视角,以更好地理解护士如何促进从接近失误中学习以改善组织结局。本研究旨在了解临床护士对采用二级解决问题行为从接近失误中学习的观点和感受,为进一步制订患者安全管理策略提供参考。方法采用半结构访谈法,对北京市3所三级综合医院的19名临床一线护士进行访谈。以Crossan的4I[直觉(intuiting),解释(interpreting),整合(integrating),制度化(institutionalizing)]组织学习模型为框架,采用内容分析法对资料进行分析。结果基于“4I组织学习模型”,共提炼出4个主题。护士认为二级解决问题行为是:充当带头人,主动并鼓励他人报告接近失误;利用有限的个人能力及职权尽可能推动对接近失误原因的探究;在关于接近失误的质量改进项目中,既要主动参与,又不逾越自身的职责权限;在正视自身话语权有限的事实下,对质量改进措施进行效果反馈并提出完善建议。结论基于4I组织学习框架,可引导临床护士在推动组织层面从接近失误中学习的过程中发挥作用。本研究中,通过二级问题解决行为,临床护士在推动组织从接近失误中学习的过程中起到了重要作用。但护士需要额外的知识、技能和支持,在意识到接近失误时能最大限度运用二级解决问题方式,以促进患者安全。