McDonald R, Waring J, Harrison S, Walshe K, Boaden R
National Primary Care Research and Development Centre, University of Manchester, Manchester, UK.
Qual Saf Health Care. 2005 Aug;14(4):290-4. doi: 10.1136/qshc.2005.013912.
The current orthodoxy within patient safety research and policy is characterised by a faith in rules based systems which limit the capacity for individual discretion, and hence fallibility. However, guidelines have been seen as stifling innovation and eroding trust. Our objectives were to explore the attitudes towards guidelines of doctors and nurses working together in surgical teams and to examine the extent to which trusting relationships are maintained in a context governed by explicit rules.
Fourteen consultant grade surgeons of mixed specialty, 12 consultant anaesthetists, and 15 nurses were selected to reflect a range of roles. Participant observation was combined with semi-structured interviews.
Doctors' views about the contribution of guidelines to safety and to clinical practice differed from those of nurses. Doctors rejected written rules, instead adhering to the unwritten rules of what constitutes acceptable behaviour for members of the medical profession. In contrast, nurses viewed guideline adherence as synonymous with professionalism and criticised doctors for failing to comply with guidelines.
While the creation of a "safety culture" requires a shared set of beliefs, attitudes and norms in relation to what is seen as safe clinical practice, differences of opinion on these issues exist which cannot be easily reconciled since they reflect deeply ingrained beliefs about what constitutes professional conduct. While advocates of standardisation (such as nurses) view doctors as rule breakers, doctors may not necessarily regard guidelines as legitimate or identify with the rules written for them by members of other social groups. Future safety research and policy should attempt to understand the unwritten rules which govern clinical behaviour and examine the ways in which such rules are produced, maintained, and accepted as legitimate.
患者安全研究与政策领域当前的正统观念表现为对基于规则的系统深信不疑，这种系统限制了个人的自由裁量权，从而减少了犯错的可能性。然而，指南却被视为抑制创新并侵蚀信任。我们的目标是探究外科团队中医生和护士对指南的态度，并考察在由明确规则所支配的环境中信任关系得以维持的程度。
挑选了14名不同专业的顾问级外科医生、12名顾问麻醉师和15名护士，以反映一系列角色。参与观察与半结构化访谈相结合。
医生对于指南对安全及临床实践的贡献的看法与护士不同。医生拒绝书面规则，而是遵循构成医学专业人员可接受行为的不成文规则。相比之下，护士将遵守指南视为专业精神的同义词，并批评医生不遵守指南。
虽然营造“安全文化”需要一套关于被视为安全临床实践的共同信念、态度和规范，但在这些问题上存在意见分歧，且难以轻易调和，因为它们反映了关于什么构成专业行为的根深蒂固的信念。虽然标准化的倡导者（如护士）将医生视为规则破坏者，但医生不一定认为指南是合理的，也不一定认同其他社会群体为他们制定的规则。未来的安全研究和政策应试图理解支配临床行为的不成文规则，并考察这些规则产生、维持以及被视为合理的方式。
