Problems at the point of care frequently arise. How the
front-line staff addresses those problems affects the capability
for organizational learning. The most common staff response to a
problem is one that prevents learning.
“Fixing the problem” is a first-order response. It serves its
purpose for that specific event but does little to prevent future
problems. Typically, a nurse will work around the problem or
correct it so that the patient gets what is needed. If the nurse
does not know how to fix the problem, he or she will typically
ask a colleague for help. Once the problem is fixed or obstacle
surmounted, it receives no more attention and any underlying
causes (e.g., an unrealistic policy or a difficult-to-use device)
are not addressed.
The second-order response is to identify the cause of the problem
and take steps to prevent future problems. For any but the most
isolated problem this is preferred, although a temporary fix may
be necessary for current care.
However, one study showed that 92 percent of the time nurses stop
with the first-order response. The study identified three factors
causing this and suggested some solutions.
Nurses tend to embrace personal responsibility to overcome
obstacles and deliver care, which can lead to overreliance on
Time-pressures and lack of readily available front-line
improvement resources make it difficult to start working on
An authority gradient between nurses and administrators, or
nurses and doctors, can inhibit “speaking up.”
The authors provide six suggestions:
Make root cause removal part of the job expectation and allocate
time for it.
Open up lines of communication between front-line workers and
those that supply them resources (e.g., materials management,
information technology) to provide spontaneous feedback
Increase attention to front-line complaints and attach a positive
connotation to being a complainer.
Provide system improvement resources for front-line workers. For
example, give a person knowledgeable in performance improvement
the responsibility to assist the workers’ problem solving.
Openly encourage solution identification, but with an
appreciation for its effect on other departments. Localized
solutions otherwise may ignore adverse system consequences.
Publicize front-line workers’ successes to encourage others to