Preventing Learning

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 self-help.

Time-pressures and lack of readily available front-line improvement resources make it difficult to start working on causes.

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 opportunities.

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 participate.