Quick Fixes and Hospital Learning

In 2003, Anita Tucker and Amy Edmonson published an important article on organizational learning: Why Hospitals Don’t Learn from Failures. Their study examines the way nurses on the frontlines respond to the daily problems they encounter in trying to care for patients. Tucker and Edmonson studied nurses in nine nursing units within nine different hospital settings. They define problems “as a disruption in a worker’s ability to execute a prescribed task because: either something the worker needs is unavailable in the time, location, condition, or quantity desired and, hence, the task cannot be executed as planned; or something is present that should not be, interfering with the designated task” (p. 57). Missing medications, missing information, missing supplies are examples of problems.

Problems tend to be visible. Nurses are aware of a problem when they encounter one; and, the frequency with which problems occur on the frontlines suggests that bedside nurses are critically important eyes for the hospital. Because of where they are positioned within the hospital, frontline nurses see the organization from a different vantage. When the bedside nursing perspective (which includes the granular, day-to-day details regarding a patient’s care) is juxtaposed against a nursing manager’s or clinical pharmacist’s or doctor’s perspective, the hospital has a more complete picture of how the organization is performing. It stands to reason then, that knowing how frontline workers respond to problems is a necessary precondition for hospital improvement.

Tucker and Edmonson distinguish between first- and second-order problem solving of the nurses who they observed. Their nomenclature is similar to what Argyris and Schon refer to as single and double loop learning. First-order is a quick fix, a solution that allows for immediate continuity of service delivery but does not address underlying causes. Indeed, similar problems will persist and possibly worsen over time. Tucker and Edmonson found that nurses used first-order problem solving, the quick fix, the overwhelming majority of time. This strategy allowed them to continue caring for their patients without contributing to organizational learning. Moreover, first-order problem solving is often reinforced when workers experience a sense of gratification and accomplishment. That is, when a worker figures out how to work around an obstacle, it feels reaffirming.

Second-order problem solving occurs when the worker not only solves the immediate problem, but also takes steps to address the underlying causes. In this way, second-order problem supports organizational improvement. But this type of problem solving can only occur if people have the resources (such as communication systems and time) to share information as well as a culture that encourages this type of learning and discovery.

In a fascinating twist, Tucker and Edmonson uncover three valued worker attributes that may, paradoxically, undermine second-order problem solving and thereby limit organizational learning.

      Why aren’t hospitals learning all they can from daily problems
      encountered by their workers? Our research suggests that it is not
      because problems are highly complex or difficult to solve, nor is it
      because nurses are unmotivated. The problems we observed were
      neither ill-defined nor technically challenging. Instead, they were
      relatively straightforward and embedded in routine processes. It is
      also not because nurses are uncommitted, lazy or incompetent. The
      lack of organizational learning from failures can be explained
      instead by three less obvious, even counterintuitive reasons: an
      emphasis on individual vigilance in health care, unit efficiency
      concerns, and empowerment. These three factors, while seemingly
      beneficial for nurses and patients alike, can ironically leave nurses
      under supported and overwhelmed (p. 62).

Tucker and Edmonson suggest that hospitals highly value and promote individual vigilance, the initiative and responsibility to tackle problems when those problems present. But individual vigilance “can create barriers to organizational improvement because, in addition to encouraging individuals to be alert to things that can go wrong … norms of individual vigilance encourage independence. Each caregiver thus tends to work on completing her or his own tasks without altering common underlying processes” (p. 63).

Second, the hospital culture is one that tends to maximize efficiencies such as reduced hospital stays. What this means is that time to engage in second-order problem solving is not structurally wired into a hospital’s DNA. When the culture of efficiency results in nursing staff who are racing to complete their required tasks within a limited amount of time, then that organizational structure is essentially enabling and reinforcing the quick-fix, first-order problem solving approach.

The third attribute Tucker and Edmonson identify is empowerment (that which enables one to act). Nursing research on empowerment (see Linda Aiken’s work) suggests that empowered nurses are more highly motivated, experience less burnout, and less job strain than disempowered nurses. Though empowerment has a lot of appeal, “the flip side … is the removal of managers and other non-direct labor support from daily work activities, leaving workers on their own to resolve problems that may stem from parts of the organization from which they have limited interaction”(p.64). Managers often have status and resources that allow them to more readily resolve problems as well as implement changes at scale.

The dynamic that Tucker and Edmonson articulate in their article can be easily mapped using STELLA, the systems thinking modeling program from ISEE systems. Below is a systems thinking map that visualizes how the quick fix approach prevents an organization from improving, thereby enabling the stressful conditions our healthcare providers perpetually work against.

 
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