Barriers and Enablers of Second-Order Problem-Solving Behavior: How Nurses Can Break Away From the Workaround Culture : Quality Management in Healthcare

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Special Section on Nursing Challenges and Solutions

Barriers and Enablers of Second-Order Problem-Solving Behavior: How Nurses Can Break Away From the Workaround Culture

Vanbelleghem, Sem MSc, RN; De Regge, Melissa PhD, MSc, RN; Van Nieuwenhove, Yves MD, PhD; Gemmel, Paul PhD

Author Information
doi: 10.1097/QMH.0000000000000385


Hospital nurses spend a substantial part of their time working around operational failures (OFs) or breakdowns in system processes. OFs occur when something is incorrect, illegible, ambiguous, damaged, untraceable, or miscommunicated. The transport monitor is missing; regular-diet food trays are delivered for diabetic patients; there is insufficient stock of linen; change-of-shift reports are incomplete; waiting times rise to 1.5 hours for necessary supplies such as blood products, etc. These easily recognizable examples of OFs are seemingly minor problems perceived as one-off, inevitable, or routine occurrences.1 When OFs hinder the processes of patient care, nurses use temporary solutions or workarounds to bypass the hindrance.2 As a result, the immediate problem is solved, but the underlying conditions that gave rise to the problem remain unaffected. Tucker & Edmondson3 call this first-order problem-solving behavior (FOPSB). For instance, when a pulse oximeter is defective, a very common solution is to borrow a device from another nursing unit. The problem with this workaround thinking is that it merely transfers the original problem to another time, person, or place.4 Halbesleben et al.5 found that 95% of OFs encountered by nurses are managed through FOPSB. In only a minority of cases do nurses try to understand why the problem occurs, with the aim of eliminating the underlying causes and preventing similar failures in the future. This behavior is called second-order problem-solving behavior (SOPSB).6 When there is a chronic shortage of linen, an example of SOPSB is contacting the central service department to increase supplies to avoid the same problem in the future. SOPSB is an intentional learning activity,7 pushing forward the cause analysis, trying out improvement projects, and promoting continuous improvement.8 The importance of hospitals learning from their failures hardly needs to be stated. Beyond the negative aspects of patient harm9 and escalating costs,10 individual and organizational performance are hampered and burden and discourage personnel, often exacerbating employee turnover, burnout, and nurse shortages.11 However, nurses fail to break away from the workaround culture, compromising hospitals' efforts to improve their processes.


Nurses encounter roughly 1 OF per hour, and dealing with these takes valuable time away from patient care. According to one study,12 an average of 44 minutes per nurse per 8-hour shift is wasted on failure resolution activities, which would be equivalent to transferring 1 out of every 15 nurses from patient care to full-time work obtaining supplies, information, and equipment. For this reason, nurses as frontline workers are in an excellent position to identify OFs and should be able to provide organizations with rich, real-time information about system operations, which could improve organizational reliability and enhance organizational learning.13 This thinking accelerated since the Institute of Medicine's 2000 report To Err Is Human advised managers to focus on faulty and deficient work systems rather than blaming individuals for poor outcomes.14 This remains one of the key recommendations in the final report to Congress on “strategies to improve patient safety” from the Agency for Healthcare Research and Quality.15 Our theoretical basis draws on the model of hospital nurse problem solving introduced by Tucker and Edmondson.3 This model proposes that coaching, support, and skill from the nurse manager, along with features of the organizational context—education, self-management, work design, group norms, and reward interdependence—influence nurses' problem-solving behavior through the mediating variable of nurse cognition, including psychological safety and motivation. Although this model is valid and widely cited, recent literature indicates that the occurrence of OFs in the nursing workplace is still a substantial problem.4,8,16 Most research on problem-solving behavior of hospital nurses is based on Tucker and Edmondson's model. Therefore, 2 decades later, this study seeks new insights that may reinforce the tendency to engage in SOPSB.



The aim of this review is to shed light on the barriers and enablers of nurses' SOPSB and their consequences, so that hospitals can learn from failure and improve organizational outcomes.


The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines were used to systematically review primary research studies.17

Search methods

Search strategy

A systematic literature review of empirical studies was undertaken in August 2020. To identify relevant studies, 6 databases were consulted, and the snowball technique and reference tracking were used. Searches were performed in PubMed, Embase, Web of Science, CINAHL, Cochrane, and Google Scholar. All databases were browsed using the following keywords and the 2 Boolean operators AND/OR: nurse*, nursing, problem solving, operational failure*, workaround*/work-around*, rework, healthcare/health care. Studies related to workarounds and interruptions were excluded if they were not associated with OFs. To exclude failures related to kidney, liver, heart, organ, therapies, and therapy, these words, as well as cancer and medicine, were combined with NOT.

Inclusion and exclusion criteria

The inclusion criteria were as follows: the study (1) was available in the English language, (2) was published in a peer-reviewed journal, (3) presented empirical data from primary research or a literature review, (4) was related to health care, and (5) focused on nursing staff in a hospital setting. Studies were excluded when the primary topic of the study (eg, interruptions, problem-solving, or workarounds): (1) could not be related to OFs, (2) focused on nursing care problems (eg, complex wound care), (3) assessed nursing education, (4) related to disease-specific failures, (5) linked to adverse events due to medical intervention, and (6) was published as a dissertation, book, or conference paper.


Duplicate records were excluded using EndNote X9, and the retrieved records were screened by 1 author based on titles, keywords, and abstracts. A second author verified all the selected titles and abstracts according to the inclusion and exclusion criteria. Following abstract screening, the remaining records were retained for full-text review, conducted independently by 2 authors. The results were compared and discussed for eligibility in several team meetings with all authors, facilitated by Rayyan software.18

Search outcomes

The search identified 1898 studies. After removing 316 duplicates, 1582 studies remained. Of these, 1535 studies were excluded because their titles and abstracts did not meet the basic inclusion criteria. Forty-seven studies were thus retrieved for full-text review, during which a further 23 studies were excluded. Backward and forward citation-following of the remaining 24 studies yielded 2 additional studies that met the inclusion criteria. A total of 26 studies were thus included in this review. Details of the search and selection process can be found in Figure 1.

Figure 1.:
PRISMA flowchart of article selection.

Quality appraisal

Two authors independently used the Mixed Methods Appraisal Tool (MMAT), version 2018.19 We included quantitative, qualitative, and mixed-method studies, and this instrument has been verified to be a reliable and valid tool for assessing the quality of studies with diverse designs. For each MMAT item, interrater reliability was estimated using the kappa statistic.20 The reliability of the MMAT varied by criterion, from substantial (0.61-0.80) to perfect agreement (0.81-1.00), with a 0.936 kappa for global appraisal. Overall, the quality of the studies was high, and none was excluded from the review based on MMAT score. Quality ratings for each study can be found in Supplemental Digital Content Table S1 (available at:

Data extraction and synthesis

A synthesis data extraction table was created using Microsoft Excel, as shown in Table 1. This method provides an approach for combining, aggregating, integrating, and synthesizing primary research findings21 to ensure consistency in our review, while reducing bias and improving validity and reliability.22 Due to the methodology and heterogeneity of the included studies, it was not possible to carry out a meta-analysis, so results were presented as a narrative summary.

Table 1. - Data Abstraction Table
Reference (Country) Aim/Purpose Study Design Setting, Participants Key Findings
Beaudoin and Edgar11 (Canada) To examine how hassles affect the quality of nurses' work lives Focus group interviews 1 hospital, 121 RNs Hassles prevent nurses from performing patient care and increase nurse dissatisfaction
Social/environmental hassles were reported most frequently, then operational hassles.
Bijl et al.38 (the Netherlands) To investigate the relationship between lean adoption and PS behavior in nursing teams Mixed-methods retrospective multiple case study 1 hospital, 3 members of 14 nursing teams A strongly significant positive relationship between Lean maturity and SOPSB
Semi-structured interviews
Debono et al.2 (United States) To assess the perceived impact of nurses' use of WOs in acute care settings Scoping review 58 studies Workarounds enable, yet potentially compromise, the execution of patient care
Collegiality, organizational and cultural norms play a role in nurses' use of WOs
Gemmel et al.6 (Belgium) To investigate if Lean implementation stimulates nurses' SOPSB Vignette-based qualitative survey 2 hospitals, 2 × 2 wards, 31 RNs Nurses in hospitals with an extensive Lean implementation show more SOPSB than those in hospitals with a stand-alone approach in a single department
Ghosh and Sobek32 (United States) To examine empirically the role of a systematic PS routine in the process improvement efforts of hospitals Multiple case research designSemi-structured interviews 140-bed hospital, 18 cases, 1200 employees Hospital managers can improve patient care and increase operational efficiency by adopting and diffusing problem-solving routines
Gurses and Carayon26 (United States) To identify the performance obstacles experienced by IC nurses in their work environment Multisite, cross-sectional study36-item questionnaire 7 hospitals (17 IC units), 272 RNs Most frequently experienced performance obstacles: noisy work environment, distractions from family, hectic and crowded environments and medication delays from pharmacy
Halbesleben and Rathert37 (United States) To examine the role of Continues Quality Improvement (CQI) and Psychological Safety as predictors of WOs Cross-sectional field studyTelephone survey Multiple hospitals, 83 employees Predictors of WOs: personal influence, management style and psychological safetyFindings suggest that organizations need to commit to CQI at a strategic level to avoid WOs
Halbesleben et al.30 (United States) To examine rework and WOs in hospital medication administration processes Constant comparative methodObservations, semi-structured interviews, process mapping 4 hospitals IC units, 58 RNs Barriers: 1/information exchange 2/information entry 3/internal supply change
Halbesleben et al.55 (United States) The purpose is to validate a new tool to measure nursing WOs Multiple approaches to psychometric testing
Contact list of RNs in Minnesota, 460 RNs Evidence was found for the content, factorial, discriminant, and criterion-related validity of the new tool
Halbesleben et al.5 (United States) Reviewing the existing literature concerning WOs Literature review Number of studies unknown To avoid the negative effects of WOs: open (cross-disciplinary) discussion of work processes and consider the role that organizational climate and culture play in the development of WOs
Hall et al.27 (Canada) To examine the processes and factors that are connected with interruptions and the outcomes of these Mixed-method research designWork observations and focus groups 3 hospitals (6 units), 30 RNs Main sources of interruptions: other nurses 25%, factors in the work environment 19.0%Main causes: communication related to the patient 57.3%, waiting/searching 22.0%
Hewitt and Chreim1 (Canada) To investigate whether nurses, when faced with safety problems, forget about it or report it Qualitative case study designIn-dept interviews Tertiary care hospital, 40 health care practitioners Fix and forget was the main choiceNear misses are often unworthy of reporting
Holden et al.34 (United States) To investigate how BCMA technology affects nursing work, particularly nurses' operational problem-solving behavior Cognitive systems engineering observations and interviews Tertiary care hospital, 40 health care practitioners The impact of BCMA on PS behavior suggests that design needs to include anticipatory control, ecologically valid design, and IT usability
Mansour and Tremblay29 (Canada) To investigate how to decrease burnout and safety WO behaviors in health care organizations Cross-sectional studySurvey Province of Quebec (via the union of RNs), 562 responses; 68% RNs If the psychological safety climate is high, employees should experience less burnout and in turn less likely use WOs
Stevens et al.13 (United States) To describe the rate and categories of OFs detected by nurses while providing direct patient care Prospective, cross-sectional descriptive (multisite) study 23 hospitals (67 adult and pediatric medical-surgical units), 774 RNs On average, RNs reported 6.1 OFs/12-h shiftHighest rate in category equipment/suppliesOFs consume 10% of nurses' time
Stevens and Ferrer24 (United States) To investigate a self-report approach to detect OFs by frontline care providers Descriptive cross-sectionalPocket card 5 medical-surgical units, 160 RNs Mean number of OFs per shift varied from 4.0 to 8.5 problemsEquipment/supplies were most commonly reported
Tucker12 (United States/Canada) To investigate the nature of OFs encountered by RNs and what effect they have on employees and patients In-dept studyShadowing and semi-structured interviews 9 hospitals, 26 RNs Nurses encounter 6.5 OFs/8-h shift and 9% of nurses time (44'/8-h shift) was wasted on failureApproximately $95/h per nurse was lost to OFs
Tucker23 (Unites States/Canada) To investigate the conditions under which frontline employees take initiative to improve their work systems to prevent OFs Cross-sectional, single-wave, multiple-hospital surveys 14 hospitals (37 units), 389 RNs Psychological safety and problem-solving efficacy were positively correlated with frontline system improvementFelt responsibility was negatively associated
Tucker36 (United States) To understand the link between work blockages and employee behaviors in a health care setting Laboratory experimentObservations and survey Physical setup at 2 conferences, 183 RNs Increase communication about operational failures by deliberately making it difficult to work around them while providing a high level of access to process owners
Tucker and Edmondson3 (United States) To consider how work environment and manager behavior influence frontline health care workers' responses when faced with problems Qualitative studyObservations and interviews 9 hospitals, 26 RNs This study highlights the importance of nurse manager coaching, training, self-management, work design, group norms, psychological safety and the use of a PS coordinator
Tucker and Edmondson25 (United States) To develop understanding of and recommendations for organizational learning from process failures In-dept studyShadowing and semi-structured interviews 9 hospitals, 26 RNs This study introduces a balancing loop of the iterative relationship between problems and worker response
Tucker et al.35 (United States) This study investigated how the context of front lines affects workers' responses to routine problems Inductive field studyObservations 8 hospitals, 22 RNs Nurses engage in SOPSB for only 8%The lack of available time, and the necessity to continue patient care contribute to a pattern of frontline workers rarely engaging in root cause removal
Tucker et al.56 (United States) To investigate organizational factors that contribute to OFs related to hospital room turnover Human-centered designObservations and interviews 2 hospitals, 89 employees This study proposes 4 dimensions of interconnectedness to increase cooperation among hospitals' internal supply departments
Tucker et al.27 (United States) To contrast the safety-related concerns raised by frontline staff about hospital work systems with national patient safety initiatives Qualitative studyObservations and open discussion meetings 20 hospitals The 2 most frequent categories of OFs, equipment/supplies and facility issues, posed safety risks and diminished staff efficiency, but have not been priorities in national initiatives
Tucker and Spear28 (United States) To examine the frequency of work systems and their impact on nurse productivity Cross-sectionalPrimary observation, semi-structured interviews and surveys 6 hospitals, observation (11 RNs), interviews (6 RNs), and survey (48 units) 8.4 work system failures per 8-h shiftTop 5 types of failures: medications, orders, supplies, staffing, and equipmentInterruptions: 8 times/shift
Tucker et al.33 (United States) To measure WO behaviors and OFs and their impact on patient outcomes Qualitative studySurvey. 63 hospitals (292 units), 4,741 RNs. This study provides evidence that WOs may be associated with negative patient outcomes, if they stem from a process-avoiding approach
Abbreviations: BCMA, bar-coded medication administration; IC, intensive care; OF, operational failure; PS, problem-solving; RN, registered nurse; SOPSB, second-order problem-solving behavior; WO, workaround.


Study characteristics

All studies were published over the 18-year period between 2002 and 2019, with half of them published since 2013 and 4 published in 2019. The studies were conducted in developed countries, including: the United States (18); Canada (4); the United States/Canada (2); the Netherlands (1); and Belgium (1). Three independent authors (Tucker, Halbesleben, and Stevens) represent almost 60% (n = 16) of all studies, of which Tucker is an author of 10 studies, or 38% of all studies. The articles were published in peer-reviewed sources in various fields, mainly in health care journals (n = 18); 7 of these were in nursing journals and 6 were in management journals. Other fields include operations management (n = 4), change management (n = 2), personnel (n = 1), and technology (n = 1). Researchers gathered data through observations (n = 1), interviews (n = 6), observations with subsequent interviews (n = 9), surveys (n = 5), observations and survey (n = 1), pocket cards (n = 2), and online databases (2). Details can be found in Table 1.

Reported outcomes

This study consecutively reviews OFs and FOPSB, followed by the barriers and enablers of SOPSB. We define barriers as impediments that discourage problem-solving behavior, while enablers facilitate and support this behavior.

Operational failures

To better understand nurses' direct experience with OFs, several studies examined the frequency and type of OFs encountered by frontline nurses. Nurses on average encounter roughly 1 OF per hour, or 6.5 OFs per 8-hour shift.13,23,24 To categorize the observed OFs, most studies used the 5 broad types of nursing problems derived from the observational research of Tucker and Edmondson,25 which include missing or incorrect information, missing or broken equipment, waiting for a (human or equipment) source, missing or incorrect supplies, and simultaneous demands on workers' time. Four studies added other types: missing medication and insufficient staffing,23 physical unit/layout,13,24 and time availability and scheduling of activities.26 The most common types of OFs were associated with equipment, supplies, and missing or incorrect information.27

The occurrence of OFs has several important consequences. For nurses, dealing with OFs takes valuable time away from patient care. An average of 44 minutes per nurse per 8-hour shift is wasted on failure resolution activities,28 which is equivalent to transferring 1 out of every 15 nurses from patient care to full-time work obtaining supplies, information, and equipment. Moreover, these OFs are rarely captured by workload measurements systems.12 The loss of nursing time is also reflected financially, given that nurses account for a quarter of a hospital's budget. With an estimated median cost of $117 per OF, approximately $95/hour per nurse is lost, which equates to $256 000 per year of nursing time loss for a 200-bed hospital.25 OFs interfere with nurses' work by disrupting or delaying their ability to do their real job, leading to heavy workloads and rework.29,30 As a result, nurses experience increasing stress and frustration,11 which often exacerbates staff turnover, burnout, and nurse shortages.23 Furthermore, OFs have a significant impact on organizational and clinical processes, as they lead to interruptions and errors of work systems,11,31 disrupt planning and workflow,26,31 and decrease individual and organizational performance and productivity.28 Studies linking OFs and patient safety remain vague, referring only to interruptions and delays in patient care,12,31,32 negative consequences for patients,11 and patient safety problems.27,33

First-order problem-solving behavior

FOPSB occurs when a worker attempts to compensate for an immediate problem, to finish a task that was blocked or interrupted, but does not try to alter the underlying conditions that created the problem or to prevent a similar problem from occurring.3 According to Holden et al,34 FOPSB involves “short-term fix” solutions or patches that are applied “on the fly” to fulfill some more or less immediate goal. A similar definition exists for workarounds, which are an example of FOPSB.5

FOPSB covers 92% of responses to OFs,35 and there are a number of explanations for this. First, short-term solutions or workarounds allow patient care to continue. This may be reinforced by the frontline context in which nurses work, where immediate responsibilities outweigh the potential future benefits of improvement efforts.35 Second, due to the frequent occurrence of OFs, nurses assume that FOPSB is part of their work routine and take on this additional, nonnursing and unwanted work without questioning.11 Mansour and Tremblay29 refer to the idea that health care has a workaround culture, in which expertise in bypassing obstacles to get the job done is valued. Third, frontline workers do not have time to engage in activities outside of their immediate patient care responsibilities. Moreover, 9 out of 10 nurses observed by Tucker et al35 worked an average of 42 minutes after their shift because they were unable to complete their regular tasks within the allotted time. Nurses prioritize their tasks, and due to time constraints, system improvements are not a priority.12 Fourth, nurses may avoid discussing OFs because of fear of being perceived as incompetent, a troublemaker, or a complainer.36 A final explanation is that FOPSB provides psychological self-fulfillment and feelings of gratification among nurses when they effectively overcome problems on their own. Competencies like independence, creativity, and perseverance appear to be reinforced by a work context that encourages nurses to work as autonomously as possible, using quick solutions to work around system failures.35 Tucker and Edmondson25 described this as individual vigilance, an industry norm that encourages nurses and other health care professionals to take personal responsibility to solve problems as they arise. This individual vigilance is explicitly developed and highly valued in health care organizations.

At first glance, FOPSB seems successful. But upon further review of the literature, it appears that it also can be counterproductive. We here discuss some pros and cons of FOPSB. Two beneficial effects of FOPSB have already been mentioned: it allows continuity of patient care, and gives psychological self-fulfillment and feelings of gratification to nurses who solve problems effectively on their own. Workarounds are responses to OFs, and they can be valuable opportunities to improve work processes. In an environment that facilitates continuous quality improvement, workarounds add flexibility and innovation to a system, allowing employees to experiment and suggest improvements without sacrificing the efficiency and quality of a task.37 Beyond this, workarounds can be time-saving and inexpensive. A common example is that hospital nurses regularly borrow medication or linen from another patient or nursing unit when the lack of such items threatens the continuity of their care for the patient. However, this FOPSB does not address underlying causes, and thus does not reduce the likelihood of a similar problem from recurring.38 Consequently, the physical and cognitive workload of nurses increases as a result of recurrence and rework.29 Furthermore, using nurses to execute nonnursing tasks can be prohibitively expensive compared with the cost of hiring a nonprofessional worker to perform these tasks.11 Employees rarely inform the person responsible for the problem, so communication about failures remains isolated and the organization's learning opportunities are compromised.5 Many first-order solutions have downstream negative consequences for others. For example, when nurses respond to missing equipment or linen by getting supplies from other storage locations, depleting their stock, future shortages may occur for others.5 The literature assumes that FOPSB also has a negative effect on process standardization, particularly when safety procedures are bypassed through workarounds in an attempt to save time.33 In general, first-order problem-solving outcomes range from minor but annoying problems to more unsafe situations with potentially hazardous consequences.35Table 2 summarizes the reasons nurses are strongly committed to FOPSB, and outlines the downsides of FOPSB.

Table 2. - Reasons for Commitment to FOPSB, and the Downsides of FOPSB
Reasons for Commitment to FOPSB Downsides of FOPSB
FOPSB allows patient care to continue FOPSB increases the likelihood of recurrence of a similar problem
Nurses assume FOPSB is part of their work routine FOPSB increases the physical and cognitive burden of relapse
FOPSB avoids giving the impression of being incompetent, a troublemaker or a complainer Consequences of FOPSB range from minor but annoying problems to potentially hazardous consequences
FOPSB provides psychological self-fulfillment and gratification FOPSB may have downstream negative implications on others
Workarounds are opportunities to improve work processes FOPSB has a negative effect on the standardization of processes
Workarounds can be time-saving FOPSB compromises the organization's learning opportunities
Workarounds can be cost-effective Using nurses to execute nonnursing tasks is expensive
Abbreviations: FOPSB, first-order problem-solving behavior; SOPSB, second-order problem-solving behavior.

Barriers and enablers of second-order problem-solving behavior

SOPSB occurs when the employee, in addition to patching the problem so that the task at hand can be completed, also takes action to address the problem's underlying causes and attempts to change the system so that it does not reoccur.25,34,38 However, when nurses encounter OFs, they engage in SOPSB in only 8% of cases, and their efforts are often opportunistic, inadequate, and not recognized as a goal for organizational improvement.35 There are several explanations for this low level of commitment in root cause analysis. We consecutively discuss the barriers and enablers of SOPSB.

Barriers to second-order problem-solving behavior

First, the frontline context in which nurses work is structured to favor FOPSB, with immediate responsibilities outweighing the potential future benefits of improvement efforts. The tasks carried out by nurses are knowledge-intensive, highly diverse, and performed in the physical presence of patients, so the nurse is more focused on the current patient's comfort and safety, and may be less aware of the need to strengthen the organizational system through which care is delivered.25 Second, the short-term effect of FOPSB reduces the urgency of engaging in SOPSB.35 Third, the more effort put into FOPSB, the less likely nurses are to proceed with root cause analysis. However, if OFs can be worked around quickly and easily, employees will not contribute ideas of improvement.36 Fourth, SOPSB is often hindered by a lack of communication about problems. Nurses often engage in opportunistic problem communication, as they lack easy and convenient methods to communicate about OFs. Moreover, if it is easy to work around OFs, nurses are likely to remain silent about them.30 Fifth, the sense of gratification that nurses experience when they effectively solve problems themselves reduces SOPSB. Nurses and other health care professionals are encouraged to take personal responsibility in solving problems as they arise. In fact, nurses who highlight the shortcomings of others or express dissatisfaction with poorly coordinated hospital systems run the risk of being perceived as troublemakers or complainers.12 Sixth, nurses do not feel personally responsible for improving their work environment, but see the optimization of work systems as the responsibility of the entire unit.23 Seventh, without substantial support from the (nurse) manager and the organization, nurses find it difficult to engage in improvement efforts. In addition, managers likely underestimate the extent to which nurses are challenged with OFs, because the full extent of failures remains hidden from those not primarily involved on the front line.12 The eighth and most frequently mentioned explanation is that engaging in SOPSB requires important resources, most crucially time. Because of the perceived time constraints, nurses prioritize their tasks and give low priority to system improvements, because they divert time from what nurses see as their main responsibility: completing routine nursing tasks.5,34,36Table 3 provides a summary of the barriers to SOPSB.

Table 3. - Barriers to SOPSB
The frontline context in which nurses work; the comfort and safety of patients takes priority over the need to strengthen the organizational system
The short-term effect of FOPSB reduces the necessity of engaging in SOPSB
The more effort that is put into FOPSB, the less likely to proceed in SOPSB
If OFs can be quickly and easily circumvented, nurses will not contribute ideas for improvement
SOPSB is often hindered by a lack of communication about problems
The sense of gratification that nurses experience when they effectively solve problems themselves reduces SOPSB
Nurses who express dissatisfaction with poor hospital systems risk being seen as troublemakers or complainers
Nurses do not feel personally responsible for improving their work environment
Nurses find it difficult to engage in SOPSB without substantial support from the (nursing) manager and the organization
Due to perceived time constraints, nurses prioritize their tasks and give low priority to system improvements
Abbreviations: FOPSB, first-order problem-solving behavior; OF, operational failure; SOPSB, second-order problem-solving behavior.

Table 4. - Enablers of SOPSB
Make frontline staff aware of their crucial role in identifying and communicating OFs as a necessity for SOPSB
  • need to be physically present on the work floor to became aware of the problems that occur

  • must ensure that communication about OFs is possible at all times

  • need to decrease time pressure by providing assistance when problems arise

  • should engage in root cause problem-solving so that nurses find it worthwhile to invest in SOPSB

  • need to create a psychologically safe environment in which employees can speak up without fear of consequences

Implement reporting systems that allow employees to share experiences about OFs
Employ a problem-solving coordinator
  • working at the level of frontline staff to investigate the causes of irregularities, and initiate countermeasures

  • given the time and responsibility to communicate problems across organizational boundaries

Allocate sufficient time for nurses to participate in improvement efforts, to report OFs or speak to a key person
Abbreviations: OF, operational failure; SOPSB, second-order problem-solving behavior.

Enablers of second-order problem-solving behavior

Based on the literature review, we provide improvement proposals for health care organizations that seek to engage in SOPSB in the front line of patient care. We refer to them as enablers, because their presence positively influences, facilitates, and sustains SOPSB.

Nurses have low levels of SOPSB36 and one lever for change is empowerment through managerial support, to increase SOPSB among frontline workers.30 Managers need to be physically present on the work floor, so that they become aware of the problems that occur and to give nurses the opportunity to communicate about OFs.36,37 Furthermore, managers should encourage the discussion and analysis of minor problems, decrease time pressure by providing assistance when problems arise, and engage in root cause problem-solving, to create an environment in which nurses believe that it is worthwhile to invest in SOPSB.25,37 To learn from failures, employees must be able to speak up about them without fear of adverse consequences or punishment. Managers can help create a psychologically safe environment in which employees feel safe about taking the interpersonal risk associated with SOPSB, making this behavior more achievable.25

Health care organizations should consider using reporting systems that allow employees to report OFs or workarounds, which could lead to improvements in work processes, or at least to make management aware that FOPSB occurs and can jeopardize patient safety.37 According to Holden et al.,34 these highly structured systems for reporting, analysis, redesign, evaluation, and adjustment are often not available to frontline employees. Despite the frequent absence of reporting systems, it is essential that nurses be encouraged to communicate about daily failures so that faulty work processes can be improved.38 Communication should preferably occur immediately, while the information needed for the root cause analysis is still available. This explains why some hospitals employ a problem-solving coordinator who works on the frontline staff level, but who is given the time and responsibility for communicating about problems across organizational boundaries, investigating the causes of irregularities, and initiating countermeasures.3 Easy access to a designated person for system improvement increases the likelihood that frontline employees will speak up about OFs from 9% to 77%.36

SOPSB has to take place during regular hours in the nursing unit. As such, if nurses are encouraged to engage in SOPSB, this activity should be an explicit part of their job and should be allocated sufficient time.35Table 4 provides an overview of the enablers of SOPSB.


We initiated this study with the occurrence and consequences of OFs, which serves as one of the justifications for our review. How employees respond to an OF is reflected in their behavior, and so we highlight the reasons why frontline staff are strongly committed to FOPSB, while also outlining the downsides of this behavior. Finally, we explore the barriers and enablers of SOPSB, as suggestions for improvement for health care organizations that seek to engage in SOPSB at the frontline of patient care. To begin our discussion, we were able to distinguish 3 perspectives within the enablers of nurses' SOPSB: the “empowerment” perspective, the “process improvement” perspective, and the “time” perspective.

Empowerment emerged as an essential theme contributing to strong nurse commitment and performance.39,40 Giving nurses more self-efficacy, authority and responsibility can be a powerful enabler for SOPSB. This aligns strongly with our Results, where the empowerment perspective includes the meaningful role of frontline employees, the importance of manager support, and the necessity for a psychologically safe environment. Corder and Ronnie41 describe how nurse managers can play a pivotal role in motivating nurses. Likewise, Wei et al.42 found that nurse leaders recognize and utilize nurses' strengths at work, which enhances nurses' performance. Moreover, in a recent article, Wang et al.43 revealed a significant positive correlation between transformational leadership (ie, leaders and followers helping each other to reach higher moral and motivational levels) and psychological safety for nurses—thus emphasizing the role of psychological support and empowerment.

The process improvement perspective includes implementing reporting systems, optimizing communication about failures, and assigning a dedicated person as a system improvement resource for nurses. Nurses can express their concerns in a variety of ways, including by contacting their manager directly or having local “freedom to speak.”44–46 However, caution is advised, as the implementation of reporting systems requires the right culture, training, and feedback.44

We further identified that time is an essential and recurring factor in research into OFs, FOPSB, and SOPSB (Figure 2). OFs are time-consuming as they hinder and delay patient care, often leading to rework, extra work, and overtime for nurses. FOPSB can be time-saving when employees try to compensate for an immediate problem by means of a workaround, but in the long term FOPSB is time-consuming, as the underlying conditions causing the problem to persist and the problems therefore reoccur. Conversely, engaging in SOPSB, such as root cause analysis, requires time but is ultimately time-saving, as it reduces the likelihood of a similar problem reoccurring and initiates organizational learning and real change. The short- and long-term effects of investing time in FOPSB and SOPSB must be weighed against each other. As such, nurses need a window of opportunity (some available time) for improvement efforts or to speak to a key person. This window of opportunity is particularly important because SOPSB has to take place during regular hours in the nursing unit.

Figure 2.:
Time-saving and time-consuming aspects of OFs, FOPSB and SOPSB. FOPSB indicates first-order problem-solving behavior; OF, operational failure; SOPSB, second-order problem-solving behavior.

In conclusion, nurses must allocate time for SOPSB. However, this position encounters considerable challenges in the work environment. Nursing is a high workload profession, and frontline workers do not have spare time to engage in activities outside their immediate patient care responsibilities.35 Even more, nurses reported that important nursing tasks are often left undone because of insufficient time.47 Time scarcity among nurses is the main reason for missed nursing care and results in job dissatisfaction and a high turnover among nurses.48 The shortage of hospital nurses thus continuously increases, causing the number of patients per nurse to increase,49 which results in unrealistic nursing workload.50 This chronically high work pressure ensures that nurses continue to work under time constraints. We would like to draw the attention of hospital staff and nursing managers to the fact that time is vital for nurses to engage in SOPSB, and that opportunities must be sought on various levels to free up time.

How nurses respond to an OF is reflected in their behavior. Tucker first studied this behavior in 2002 and found that nurses exhibited either FOPSB or SOPSB. Subsequent studies, which also investigated this behavior, grounded their research on Tucker's findings and divided their observations between the same 2 types of behavior. Based on our findings, none of these studies refer to other possible behaviors. However, we suggest that a third behavior is possible. To clarify this thought, assume the patient's bed is slightly soiled and linen is not available because the stock on the unit is depleted. We reason it is possible that in this case the nurse does not take any action, neither changing the linen (FOPSB) nor acting to increase the stock (SOPSB). Thus, the task is not executed as intended or as good practice requires, and no action is taken to correct the problem afterward. With this in mind, can we speak of “no-action behavior” as a third possible behavior? It should be stated that, in our example, despite the no-action behavior, the continuity of patient care is maintained, patient safety is not compromised, and the required action is likely to be performed at another time. However, it seems plausible that there are cases where the no-action behavior could endanger the patient's outcome. Therefore, it would be important in future research to investigate the existence of this no-action behavior and its implications for patients.

Furthermore, building on this patient perspective, we found that only minimal research has been done on the consequences of OFs for patients. In fact, our results show that only 5 studies mentioned patients at all, and 4 of these did so indirectly, as they refer to “patient safety” as one of the reasons for preventing the recurrence of OFs.5,27,28,31 Only the study by Tucker et al.33 has investigated the relationship between FOPSB and patient outcomes, providing evidence that workarounds may be associated with negative patient outcomes, if they stem from a process-avoiding approach. In the other studies, OFs are investigated to prevent errors, improve work processes, initiate organizational learning, and foster the well-being of employees. These objectives are strongly process-oriented and employee-oriented, and are focused on quality evaluation and improvement. Our research has identified that patients are never the main subject, and are never consulted or involved. However, there is evidence that process-related failures can directly affect patients, for example through medication delays,30 delays in therapy or care,28 inability to carry our tests or treatment due to system technology failures, and inefficient patient care due to lack of equipment and supplies.31 This nonpatient orientation strongly differs from other health care research, including Beattie et al,51 who state that an important way of measuring the quality of care is to evaluate that quality from the patient's perspective. Moreover, the effectiveness and safety of care is likely to be well assessed by patients, as they directly affect their care experiences.52 Patients can be used as partners in identifying poor and unsafe practices53 and in helping to detect poor performance.54 As such, we are inclined to believe that the patient perspective should form part of future OF research.


This review has some limitations. First, alternative sources of information—such as gray literature, conference proceedings, and dissertations—were not included (except for introduction and background), which means that some pertinent nonacademic studies may have been missed. Second, it is well-known that the working reality of nurses differs greatly from one country to another. Our results may thus not be generalizable and should be perceived within the context from which they were extracted. Moreover, only 2 studies (<8%) from outside the United States and Canada were included in this review, both of which were in developed countries. Third, 3 independent authors (ie, Tucker, Halbesleben, and Stevens) represent almost 60% (n = 16) of all studies, of which Tucker has 10 studies, or 38% of all studies. However, to our knowledge, we included all the key literature, and therefore assume that only a limited number of researchers have investigated nurses' problem-solving behavior when confronted with OFs. Fourth, this systematic interview was limited to nurses working in hospitals. We recognize that OFs may also be experienced by nurses working in home nursing, elderly care, and the private sector. As a final limitation, the definition of an OF was not the same across all the included articles. Terms like “interruptions” and “distractions” were excluded if they could not be related to OFs. Therefore, there remains variability that will have an impact on the reported prevalence of OFs.


Nurses are challenged by numerous unexpected day-to-day problems due to poorly performing work systems. Therefore, as frontline workers, nurses are in an excellent position to prevent errors, improve work processes, initiate organizational learning, and foster the well-being of staff and patients. However, there has been hardly any research on the enablers that initiate SOPSB, so this positive nursing behavior rarely emerges as a suggestion for improvement. This study reveals some relevant gaps, such as the essential role of time as a condition for problem-solving behavior, the limited attention given to the patient's perspective, and the existence of a “no-action” behavior.


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health care; nursing; operational failures; problem-solving behavior; workaround

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