ORIGINAL RESEARCH PAPER

Year : 2007  |  Volume : 20  |  Issue : 3  |  Page : 124

Contextual Learning to Improve Health Care and Patient Safety

J Mikkelsen¹, HA Holm^2
1 Rikshospitalet-Radiumhospitalet Medical Centre, Forskningsvn. Oslo, Norway
² University of Oslo, Norway

Correspondence Address:
J Mikkelsen
Centre for Shared Decision Making and Nursing Research, Rikshospitalet-Radiumhospitalet Medical Centre, Forskningsvn. 2B, 0027 Oslo
Norway

Source of Support: None, Conflict of Interest: None

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PMID: 18080963

Context: Two unmatched blood units were transfused to a patient undergoing surgery. In order to learn from this kind of error, the department had to report the adverse event, the staff had to discuss the situation of what went wrong and why and how to improve their routines to prevent such errors in the future. In health care, learning to improve quality and safety needs to occur at the individual, team and organisational levels. However, most formal learning occurs at the individual level at the start of a professional career. Errors are too often seen as personal carelessness or incompetence to be corrected by "naming, blaming and shaming." However, errors occur within the context of teams in organisations and learning needs to move from the individual to the context. Thus, understanding and improving how health professionals work together in organisations is a crucial part of the efforts to improve patient care and safety.
Objective: The purpose of this paper is to show how health personnel can improve and avoid harmful errors in patient care by delivering care within the setting of a clinical team and addressing and analyzing errors through a systematic learning process. This paper describes this learning process in detail and shows how it can be applied to various clinical situations to improve patient safety.
Findings: Learning takes place on several levels: from single-loop learning (adaptive learning) through double-loop learning (reflection in and on action) to triple-loop learning (meta-learning), and extending ones understanding and competencies of how to learn individually and in groups. Linking professional knowledge (e.g. medical sciences) and improvement knowledge (knowledge of system improvement), and paying attention to multidisciplinary team learning, are crucial to understanding how patient care and safety can be improved in clinical microsystems.

Keywords: Contextual learning, microsystems, patient safety, health professions learning, triple-loop learning, improvement knowledge, evidence-based practice

Introduction



The purpose of this paper is to show how health personnel can improve and avoid harmful errors in patient care by delivering care within the setting of a clinical team and addressing and analyzing errors through a systematic learning process. This paper will describe the learning process in detail and show how it can be applied to various clinical situations to improve patient safety.



In health care, learning to improve quality and safety needs to occur at the individual, team and organisational levels. Errors result from physiological and psychological limitations of humans based on different causes (Helmreich, 2000). Factors determining work performance reflect organisational culture and illustrate beliefs and values that affect behaviour (Seifert & Hickman, 2005). A culture forms what and how to perform, including the way in which patients and relatives are treated and are influenced by the staff and the leaders of the organisation. The prevention and management of adverse events is important in the work of a culture that values quality and patient safety (Hjort, 2003).



Health care is delivered within a specific context, called a microsystem (Nelson et al., 2002). Examples of clinical microsystems are outpatient clinics and inpatient wards. Individual health care professionals are often trained separately, and much of this training takes place outside the context (setting) in which patients are treated (Aron & Headrick, 2002). A method of improving organisational learning is for the health professionals working within a given clinical setting to actively reflect on and discuss the processes and outcomes of their clinical decision-making, and to view this within the context of the system of patient care provided by the entire clinical team. Organisational learning takes place through analysis of processes of care; it can be judged as effective when system failures that jeopardize patient safety are identified and changes instituted within the system to improve the safety of the care delivered.



Errors are too often seen as individual carelessness or incompetence to be corrected by "naming, blaming and shaming", while the existence of systematic weaknesses remain hidden, and no lesson is learnt. A proper analysis of the event could be a starting point for organisational learning and improvement (Reason et al., 2001). Box 1 describes the context of a case from an operating theatre, within the operation department, at one microsystem in the hospital, where a patient received a mismatched blood transfusion within the setting of a surgical operation. The ordering of the blood transfusion was the appropriate response to a surgical complication; however, the method in which the order was followed up was incorrect and led to patient harm. To prevent this error from reoccurring, it is instructive to study the scenario systematically.

Box 1: Wrong blood transfusion

Two blood units were ordered for a patient undergoing surgery. During the operation, bleeding occurred, and the blood was controlled and transfusion prepared. However, the bleeding was stopped before transfusion had started. The unbroken blood units were put in a plastic bag and put back in the refrigerator. In the meantime, blood for another patient was placed in the same refrigerator. Later it was decided to transfuse the same patient, and another nurse collected the blood, but this time the blood was not checked against the identity of the patient, leading to transfusion of two units of unmatched blood.

This example shows the combined effects of problems at the individual level (nurse fails to verify the identity of the compatibility of the unit of blood with the patient’s blood type), the team level (inadequate transfer of information between team members) and the organisational level (lack of blood transfusion hospital policies). In order to learn from these kinds of errors, the department has instituted a process of correction in which “collective contextual learning” occurs. Specifically, all adverse events are to be reported to the department. Contextual learning “occurs when students apply and experience what is taught referencing real problems associated with their roles and responsibilities as family members, citizens, students and workers” (Smith & Owens, 2003). Collective contextual learning in a clinical context may then occur when health personnel learn together from real problems and adverse events in their microsystem (Nelson et al., 2002).



Single, double and triple-loop learning



The clinical microsystems in which care is delivered require constant assessment and improvement to minimize errors in patient care. Reason et al. (2001) proposed the concept ‘vulnerable system syndrome’ (VSS) and discussed two approaches to organisational learning that occur in the process of trying to address it. VSS is defined as a cluster of organisational pathologies which render some systems more liable to cause adverse events. “Single-loop” learning is adaptive learning and maintains the status quo and sustains VSS. “Double-loop” learning is about re-designing the systems rather than just correcting existing systems and putting them back on course. It is necessary to initiate the process of breaking out of VSS. They assert that the problem of patient injury cannot be mitigated through a focus on the individual health care worker alone. Rushmer et al. (2004) identify an additional loop of learning,”triple-loop” learning, that describes the process of learning about learning (“meta-learning”). Meta-learning comprises all three loops of learning and contains two elements: specific learning about that particular change that may be useful somewhere else and more generalized learning that can apply to other learning situations in a more generic way. This process is further systematized by formulating the processes of system improvement on the basis of the best available scientific evidence, complemented by clinical expertise and patient consolation (Sackett et al. 1996).



Microsystems



A clinical microsystem is defined as “a small group of people who work together on a regular basis to provide care to a discrete subpopulation of patients” (Nelson et al. 2002). In this sense, a microsystem has clinical and administrative aims, has linked processes, functions as an information-sharing environment and produces performance outcomes. Microsystems evolve over time and are often embedded in large organisations. Students meet clinical microsystems in every clinical practice setting that they encounter, such as family practices, nursing homes, hospital wards, emergency departments, surgery teams and intensive care units. These individual microsystems are connected to one another with varying degrees of closeness and typically perform better or worse under various operating conditions. At their best, microsystems consistently generate superb clinical care based on science, compassion and their unique knowledge of what patients want and need. These microsystems use data to review their performance by monitoring, managing and improving their safety and efficiency (Nelson et al., 2003). However, as an IOM report (Institute of Medicine, 2000) showed, most clinical units do not function as microsystems described here. Students and clinical staff experience microsystems through different lenses and require different strategies to facilitate effective participation in a community of practice. Lave and Wenger’s (1991) theory of ‘situated learning’ states that learning is connected to participation and action within a social context, and that opinions and identity development occur as reciprocal social processes. They posit that participation in a community of practice enhances the acquisition of the knowledge, skills of their profession and the development of their professional identity. The quality of learning will be dependent on, among other things, to what extent the learner is an integral member of the team, and the way in which senior clinical staff function as educators. A study by Kyrkjebø and Hage (2005) describing a nursing students’ experience of improvement knowledge in clinical practice showed that their learning process seemed to be negatively influenced in the community of practice by their feelings of being guests, not ‘fitting in’ and their fear of causing trouble when asking the wrong questions. For contextual learning, the community of practice - a microsystem - needs a learning environment in which students and clinical staff can combine practice and reflection with growth and development over time in a culture that is characterized by openness of beliefs, values and attitudes.



Linkage between professional knowledge and improvement knowledge



A vision for health professional, undergraduate, graduate and continuous learning is that all health professionals should be educated to deliver patient-centred care as members of a multidisciplinary team. Evidence-based practice, quality improvement approaches and informatics should all be emphasized (Institute of Medicine 2003). The aim is that students develop competency to critically evaluate the knowledge base that supports good patient care, understand the gap between prevailing practices and best practices, identify the steps to “close that gap” and participate in “closing the gap” (Association of American Medical Colleges, AAMC, 2001). This can be accomplished only through the application of reflection to achieve synthesis and create an improvement plan (double-loop learning). The teams may analyze the process and how it can be adapted to other learning situations (triple-loop learning).



To close the gap between knowledge and practice, there is a need to link the learning of professional knowledge and improvement knowledge (AAMC, 2001). Batalden & Stolz’s (1993) model of linking knowledge describes two categories of underlying knowledge that have to be linked to sustain continual improvement. The first is described as professional knowledge, which includes knowledge of subject such as anatomy, microbiology, pharmacology, communication, interactions etc. and knowledge of discipline such as medicine, nursing etc. including its theory, practice and underlying professional values. This knowledge has driven most of the traditional improvements related to the identification, treatment and care of illness (Batalden & Stoltz, 1993). The efficiency of health care has dramatically improved over the past century as new scientific developments have become available and enabled modern medicine to treat new groups of patients. Nevertheless, there has been convincing documentation over the last decade from several countries of inadequate and unsafe care that cannot be explained by lack of knowledge or resources (Institute of Medicine, 2000). Therefore, the second category of underlying knowledge concerns practical ways to change thinking about how care can be improved and made safer. This body of knowledge was described by W. Edward Deming (1993) as ‘a system for profound knowledge’, referred to as improvement knowledge. It consists of four elements: (1) knowledge of an organisation as a system of production, (2) knowledge of variations over time in processes, products and people, (3) knowledge of psychology, including the psychology of work and the psychology of change, and (4) a theory of knowledge, linking theory and practice. Improvement Knowledge (IK) includes an overall understanding of the relationship between health care quality, safety and results. This relationship is expressed in several knowledge domains: customer knowledge, system and process knowledge, knowledge of variation and measurement, collaboration knowledge and skills, and building new knowledge (Batalden et al., 1998).



The process of learning through analysis of error and implementation of corrective action is expressed in the Plan-Do-Study-Act (PDSA) cycle (Batalden & Stoltz, 1993) and it is similar to the problem-solving process (Kyrkjebø, 1999). This is another prerequisite for improving health care. Important learning takes place in the last step of the cycle, when students act and learn based on studying the results of the implemented changes (Langley, Nolan & Nolan, 1994). A study by Kyrkjebø (2006) showed that to learn improvement knowledge in clinical practice, nursing students experienced that they had to go through the whole PDSA cycle. In their clinical improvement project, they had followed a patient and looked at the patient’s day from the patient’s perspective. They had identified improvement areas, worked with evidence-based improvement suggestions without implementing and evaluating the changes to see if this was a real improvement or just a change. In other words they went through the planning phase and missed the other important phases. Cleghorn and Headrick (1996) emphasize that learning is the process of implementing the changes and studying the results, and knowing is reflecting on the decision or action as a result of learning. Therefore, it is important to help students and clinical staff to use the PDSA cycle as a systematic way of developing new knowledge through learning by experience.



Application of learning types to improve patient safety



Modern medicine is very complex and recent reports have pointed out that the issue of patient safety is a major problem. In the United States, it has been estimated that 50-100,000 patients die every year due to adverse events (Institute of Medicine, 2000; Detmer, 2003). The traditional way of dealing with adverse events has been by “naming, blaming and shaming” the health care workers who were close to the patient when the adverse event took place. Scientific studies of the nature of medical errors have demonstrated that most often the root causes are embedded in the system, like hidden pitfalls, just waiting to be activated (Volpp & Grande, 2003).



Students in health sciences do get a lot of education in the specific medical components of modern medicine, but they get nearly no training in team skills. The ability to act in teams, fostering communication, cooperation and leadership is very seldom found in the curricula in medical and nursing schools (Aron & Headrick, 2002; Kyrkjebø, 2004). In aviation, we acknowledge that crew resource management training is a crucial part of safety (Helmreich, 2000). By simulated training in teams, the pilots can and must demonstrate the ability to handle seldom occurring but life threatening situations for the maintenance of certification. This also applies to emergency medicine where the life of the patient depends on the entire team’s ability to execute the appropriate procedures in the correct order. It cannot any longer be justified that students or junior staff shall use patients as “guinea pigs” for attaining professional competence (Gaba, 2004). Simulation training has been adopted to measure improvement in patient safety.



Box 2 illustrates how interdisciplinary student teams have looked at clinical processes that have the potential of harming the patient. The student teams were challenged to apply their knowledge and experiences of professional and improvement knowledge to find ways to prevent harm, perform safe practices, and to practice and learn cooperation, communication and leadership (Kyrkjebø et al., 2006). The training programme was developed from “The BEST-model” in Norway. BEST, an acronym for “better and systematic trauma treatment”, is a model for training multiprofessional trauma teams in Norwegian hospitals using simple and low cost local simulations (Wisborg et al., 2006).

Box 2: Linking professional knowledge and improvement knowledge

A pilot project using interdisciplinary student teams (medical, nursing and intensive nurse students) in simulation training started with an introductory lesson on crew resource management (CRM), followed by a 3-4 minute video describing a case related to blood transfusion that ended with a failure - a patient was about to get wrong blood - as a trigger for discussion in the group. The discussion focused on professional knowledge related to blood transfusion and improvement knowledge related to questions on what was happening and why, and how patient harm could be prevented in this situation. Then the student groups went into two simulation trainings with scenarios related to blood transfusion. 1) Two trauma patients with quite similar names and age were admitted to the ER. Both were intoxicated and in need of blood transfusion due to several fractures. There had been a mix-up at the lab, and if the clinical staff would not carefully check the blood products and discover the error the patients could suffer serious injury. This was followed by reflections about communication, cooperation and leadership before they performed a second simulation scenario. 2) This scenario was more complicated because the patients now needed intravenous medication in addition, before the blood products arrived in the ER. In this case, there also was a risk of a serious medication error due to the erroneous placement of a concentrated electrolyte solution (Kyrkjebø et al, 2006).

Box 2 can be visualized by a flowchart (Figure 1) showing that sometimes professional knowledge (PK) is in the foreground (f) and improvement knowledge (IK) is in the background (b) and vice versa. In addition it shows the shift from single-loop learning (SLL) via double-loop learning (DLL) to triple-loop learning (TLL). The triple-loop learning is the student’s discovery of the importance of communication, cooperation and leadership which decreases the prejudice between different health professions to achieve safer care (Kyrkjebø et al., 2006).







Figure 1: Flowchart of Learning Process



Simulation as a tool to integrate professional (PK) and improvement knowledge (IK) in interdisciplinary teams, where PK is in foreground (f) and IK is in background (b) in the video setting. In the rest of the process this will change as the figure shows. The process starts with single-loop learning (SLL) and ends with triple-loop learning (TLL).



Findings



Learning is a fundamental human capability, naturally occurring in response to needs arising from internal and external demands from the very beginning of life. Peter Senge vividly expresses this in the following succinct passage:

Learning organisations are possible because, deep down, we are all learners. No one has to teach an infant to learn. In fact, no one has to teach infants anything. They are intrinsically inquisitive, masterful learners who learn to walk, speak, and pretty much run their households all on their own. Learning organisations are possible because not only is it our nature to learn but we love to learn (Senge, 1994).

It is essential that our efforts to make learning more effective and directed, supports and reinforces the individual’s and the organisation’s inherent capability to engage in continuous learning as a basis for continuous improvement. Effective learning occurs when there is an organisational culture with active oscillation between practice and reflection. Learning takes place on several levels: from single-loop learning (adaptive learning) through double-loop learning (reflection in and on action) to triple-loop learning (meta-learning) and extending one’s understanding and competences of how to learn individually and in groups. Linking professional and improvement knowledge is crucial to understand how patient care and safety can be improved. This learning, paying attention to interdisciplinary learning, occurs best when the process allows for integration of single, double and triple-loop learning grounded in evidence-based knowledge.



Acknowledgements



The authors acknowledge Professor Duncan Neuhauser, Case Western Reserve University, Cleveland, Ohio, for important advice in finishing the paper.



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